2022 Hesi exit V2
Community health nursing (Nevada State College)
2020 HESI EXIT V2
1. The nurse knows that which statement by the mother indicates that the mother understands
safety precautions with her four month-old infant and her 4 year-old child?
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year
old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while
the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I
make supper."
Answer: D
2. Upon completing the admission documents, the nurse learns that the 87 year-old client does
not have an advance directive. What action should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary
Answer: B
3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the
immunization was given, the client complains of itchy and watery eyes, increased anxiety, and
difficulty breathing. The nurse expects that the first action in the sequence of care for this
client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
Answer: B
4. Which of these children at the site of a disaster at a child day care center would the triage
nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel between crying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
D) A school-age child with singed eyebrows and hair on the arms
Answer: B
5. When admitting a client to an acute care facility, an identification bracelet is sent up with the
admission form. In the event these do not match, the nurse’s best action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client
Answer: C
6. The nurse is having difficulty reading the health care provider's written order that was
written right before the shift change. What action should be taken?
A) Leave the order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification
Answer: D
7. An adult client is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the nurse is to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway
Answer: D
8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that
800 ml has been infused after 4 hours. What is the priority nursing action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs
Answer: D
9. Following change-of-shift report on an orthopedic unit, which client should the nurse see
first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motorcycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours Ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery.
Answer: C
10. A nurse observes a family member administer a rectal suppository by having the client lie
on the left side for the administration. The family member pushed the suppository until the
finger went up to the second knuckle. After 10 minutes the client was told by the family
member to turn to the right side and the client did this. What is the appropriate comment for
the nurse to make?
A) Why don’t we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the insertion?
C) Let’s check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract?
Answer: B
11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died.
Which type of precautions is the appropriate type to use when performing postmortem care?
A) airborne precautions
B) droplet precautions s
C) contact precaution
D) compromised host precautions
Answer: C
12. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which
sequence is appropriate teaching?
A) Void a little, clean the meatus, then collect specimen
B) clean the meatus, begin voiding, then catch urine Stream
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine
Answer: B
13. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day.
Which of these foods would the nurse reinforce for the client to eat at least daily?
A) spaghetti
B) watermelon
C) chicken
D) tomatoes
Answer: B
14. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse
take?
A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management
Answer: C
15. As the nurse observes the student nurse during the administration of a narcotic analgesic
IM injection, the nurse notes that the student begins to give the medication without first
aspirating. What should the nurse do?
A) Ask the student: "What did you forget to do?”
B) Stop. Tell me why aspiration is needed.
C) Loudly state: “You forgot to aspirate.”
D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”
Answer: D
16. A client with Guillain Barre is in a non-responsive state, yet vital signs are stable and
breathing is independent. What should the nurse document to most accurately describe the
client's condition?
A) Comatose, breathing unlabored
B) Glasgow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glasgow Coma Scale 13, no ventilator required
Answer: B
17. A client enters the emergency department unconscious via ambulance from the client’s
workplace. What document should be given priority to guide the direction of care for this
client?
A) The statement of client rights and the client self-determination act
B) Orders written by the health care provider
C) A notarized original of advance directives brought in by the partner
D) The clinical pathway protocol of the agency and the emergency department
Answer: C
18. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive
personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the
nurse manager?
A) An admission at the change of shifts with atrial fibrillation and heart failure - PN
B) Client who had a major stroke 6 days ago - PN nursing student
C) A child with burns who has packed cells and albumin IV running - charge nurse
D) An elderly client who had a myocardial infarction a week ago - UAP
Answer: A
19. A mother brings her 3 month-old into the clinic, complaining that the child seems to be
spitting up all the time and has a lot of gas. The nurse expects to find which of the following
on the initial history and physical assessment?
A) Increased temperature and lethargy
B) Restlessness and increased mucus production
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
Answer: B
20. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the
parents require follow-up and are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "The urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D) "We notice muscle weakness and some unsteadiness."
Answer: C
21. A 16 year-old enters the emergency department. The triage nurse identifies that this
teenager is legally married and signs the consent form for treatment. What would be the
appropriate action by the nurse?
A) Ask the teenager to wait until a parent or legal guardian can be contacted
B) Withhold treatment until telephone consent can be obtained from the partner
C) Refer the teenager to a community pediatric hospital emergency department
D) Proceed with the triage process in the same manner as any adult client
Answer: D
22. A newly admitted elderly client is severely dehydrated. When planning care for this client,
which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
A) Converse with the client to determine if the mucous membranes are impaired
B) Report hourly outputs of less than 30 ml/hr
C) Monitor client's ability for movement in the bed
D) Check skin turgor every 4 hours
Answer: B
23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which
statement by the parent would cause the nurse to suspect an association with this disease?
A) Our child had chickenpox 6 months ago.
B) Strep throat went through all the children at the day care last month.
C) Both ears were infected over 3 months age.
D) Last week both feet had a fungal skin infection.
Answer: B
24. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a
reluctance to interact with the client. The next action by the nurse should be to Discuss the
feeling of reluctance with an objective peer or supervisor
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcement of the manipulative behavior
C) Confront the client about the negative effects of behaviors on other clients and staff
D) Develop a behavior modification plan that will promote more functional behavior
Answer: A
25. A client is being treated for paranoid schizophrenia. When the client became loud and
boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The
client willingly complied. The nurse’s action
A) May result in charges of unlawful seclusion and restraint
B) Leaves the nurse vulnerable for charges of assault and battery
C) Was appropriate in view of the client’s history of violence
D) Was necessary to maintain the therapeutic milieu of the unit
Answer: A
26. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which
nursing diagnosis should have priority?
A) Pain related to ischemia
B) Risk for altered elimination: constipation
C) Risk for complication: dysrhythmias
D) Anxiety related to pain
Answer: A
27. The provisions of the law for the Americans with Disabilities Act require nurse managers
to
A) Maintain an environment free from associated hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals
D) Consider both mental and physical disabilities
Answer: B
28. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed.
Which client statement s from the assessment data is likely to explain his noncompliance?
A) "I have problems with diarrhea."
B) "I have difficulty falling asleep."
C) "I have diminished sexual function."
D) "I often feel jittery."
Answer: C
29. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago.
Which statement from the mother indicates that teaching has been inadequate?
A) ”I will keep the cast for the next day uncovered to prevent burning of the skin."
B) ”I can apply an ice pack over the area to relieve itching inside the cast."
C) ”The cast should be propped on at least 2 pillows when my child is lying down."
D) ”I think I remember that standing cannot be done until after 72 hours."
Answer: D
30. Which statement best describes time management strategies applied to the role of a nurse
manager?
A) Schedule staff efficiently to cover the needs on the managed unit
B) Assume a fair share of direct client care as a role model
C) Set daily goals with a prioritization of the work
D) Delegate tasks to reduce workload associated with direct care and meetings
Answer: C
31. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma.
Findings observed by the nurse that is associated with this problem include which of these?
A) Lymphedema and nerve palsy
B) Hearing loss and ataxia
C) Headaches and vomiting
D) Abdominal mass and weakness
Answer: D
32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the
adolescent indicates the need for additional teaching?
A) "I will only have to wear this for 6 months."
B) "I should inspect my skin daily."
C) "The brace will be worn day and night."
D) "I can take it off when I shower."
Answer: A
33. The nurse manager has been using a decentralized block scheduling plan to staff the
nursing unit. However, staff have asked for many changes and exceptions to the schedule over
the past few months. The manager considers self-scheduling knowing that this method will
A) Improve the quality of care
B) Decrease staff turnover
C) Minimize the amount of overtime payouts
D) Improve team morale
Answer: D
34. A client is admitted to the emergency room following an acute asthma attack. Which of the
following assessments would be expected by the nurse?
A) Diffuse expiratory wheezing
B) Loose, productive cough
C) No relief from inhalant
D) Fever and chills
Answer: A
35. The nurse manager hears a health care provider loudly criticize one of the staff nurses
within the hearing of others. The employee does not respond to the health care provider's
complaints. The nurse manager's next action should be to
A) Walk up to the health care provider and quietly state: "Stop this unacceptable behavior."
B) Allow the staff nurse to handle this situation without interference
C) Notify the of the other administrative persons of a breach of professional conduct
D) Request an immediate private meeting with the health care provider and staff nurse
Answer: Dcare provider and staff nurse
36. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The
client has been on the unit for 2 days and now states “I demand to be released now!” The
appropriate action is for the nurse to
A) You cannot be released because you are still suicidal.
B) You can be released only if you sign a no suicide contract.
C) Let’s discuss your decision to leave and then we can prepare you for discharge.
D) You have a right to sign out as soon as we get an order from the health care provider's
discharge order.
Answer: C
37. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse
to a complication of this condition?
A) Dyspnea
B) Heart murmur
C) Macular rash
D) Hemorrhage
Answer: BLarge, soft, rapidly developing vegetations attach to the heart valves.
38. A nurse admits a premature infant who has respiratory distress syndrome. In planning care,
nursing actions are based on the fact that the most likely cause of this problem stems from the
infant's inability to
A) Stabilize thermoregulation
B) Maintain alveolar surface tension
C) Begin normal pulmonary blood flow
D) Regulate intra cardiac pressure
Answer: B
39. An 18 year-old client is admitted to intensive care from the emergency room following a
diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The
nurse's priority assessment should be
A) Response to stimuli
B) Bladder control
C) Respiratory function
D) Muscle weakness
Answer: C
40. The nurse is caring for a client who was successfully resuscitated from a pulseless
dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the
plan of care?
A) Hourly urine output
B) White blood count
C) Blood glucose every 4 hours
D) Temperature every 2 hours
Answer: A
41. The charge nurse on the night shift at an urgent care center has to deal with admitting
clients of a higher acuity than usual because of a large fire in the area. Which style of
leadership and decision-making would be best in this circumstance?
A) Assume a decision-making role
B) Seek input from staff
C) Use a non-directive approach
D) Shared decision-making with others
Answer: A
42. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe
for signs of which overall imbalance?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Some increase in the serum hemoglobin
D) A little decrease in the serum potassium
Answer: B
43. Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform?
A) Take a history on a newly admitted client
B) Adjust the rate of a gastric tube feeding
C) Check the blood pressure of a 2 hours post-operative client
D) Check on a client receiving chemotherapy
Answer: C
44. A child is injured on the school playground and appears to have a fractured leg. The first
action the school nurse should take is
A) Call for emergency transport to the hospital
B) Immobilize the limb and joints above and below the injury
C) Assess the child and the extent of the injury
D) Apply cold compresses to the injured area
Answer: C
45. When interviewing the parents of a child with asthma, it is most important to gather what
information about the child's environment?
A) Household pets
B) New furniture
C) Lead based paint
D) Plants such as cactus
Answer: A
46. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has
had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted
increased lethargy. Which assessment finding should the nurse report immediately to the health
care provider?
A) Slurred speech
B) Incontinence
C) Muscle weakness
D) Rapid pulse
Answer: A
47. A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his
bottom and wetting the bed at night." Based on these complaints, the nurse would initially
assess for which problem?
A) Allergies
B) Scabies
C) Regression
D) Pinworms
Answer: D
48. A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics.
In planning for home care, what is the most important action by the nurse?
A) Investigating the client's insurance coverage for home IV antibiotic therapy
B) Determining if there are adequate hand washing facilities in the home
C) Assessing the client's ability to participate in self-care and/or the reliability of a caregiver
D) Selecting the appropriate venous access device
Answer: C
49. The mother of a child with a neural tube defect asks the nurse what she can do to decrease
the chances of having another baby with a neural tube defect. What is the best response by the
nurse?
A) "Folic acid should be taken before and after conception."
B) "Multivitamin supplements are recommended during pregnancy."
C) "A well balanced diet promotes normal fetal development."
D) "Increased dietary iron improves the health of mother and fetus."
Answer: A
50. A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied
by the PN would need no further intervention by the charge nurse?
A) Telfa dressing with antibiotic ointment
B) Moist sterile non adherent dressing
C) Dry sterile dressing that is occlusive
D) Sterile occlusive pressure dressing
Answer: B
51. A nurse is providing a parenting class to individuals living in a community of older homes.
In discussing formula preparation, which of the following is most important to prevent lead
poisoning?
A) Use ready-to-feed commercial infant formula
B) Boil the tap water for 10 minutes prior to preparing the formula
C) Let tap water run for 2 minutes before adding to concentrate
D) Buy bottled water labeled "lead free" to mix the formula
Answer: C
52. A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The
most appropriate intervention for this client is
A) Position client in upright position while eating
B) Place client on a clear liquid diet
C) Tilt head back to facilitate swallowing reflex
D) Offer finger foods such as crackers or pretzels
Answer: A
53. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The
nurse knows the client understands the procedure when the client says, "I will receive tissue
from…
A) a tissue bank."
B) a pig."
C) my thigh."
D) synthetic skin."
Answer: C
54. The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis
is a priority?
A) Risk for dehydration
B) Ineffective airway clearance
C) Altered nutrition
D) Risk for injury
Answer: B
55. A client has been hospitalized after an automobile accident. A full leg cast was applied in
the emergency room. The most important reason for the nurse to elevate the casted leg is to
A) Promote the client's comfort
B) Reduce the drying time
C) Decrease irritation to the skin
D) Improve venous return
Answer: D
56. During the initial home visit a nurse is discussing the care of a newly diagnosed client with
Alzheimer's disease with family members. Which of these interventions would be most helpful
at this time?
A) Leave a book about relaxation techniques
B) Write out a daily exercise routine for them to assist the client to do
C) List actions to improve the client's daily nutritional intake
D) Suggest communication strategies
Answer: D
57. The nurse is teaching a client with non-insulin dependent diabetes mellitus about the
prescribed diet. The nurse should teach the client to
A) Maintain previous calorie intake
B) Keep a candy bar available at all times
C) Reduce carbohydrates intake to 25% of total calories
D) Keep a regular schedule of meals and snacks
Answer: D
58. The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis
B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as
long as 3 hours and has had several shaking spells. In addition to referring her to the
emergency room, the nurse should document the reaction on the baby's record and expect
which immunization to be most associated to the findings in the infant?
A) DTaP
B) Hepatitis B
C) Polio
D) H. Influenza
Answer: A
59. The nurse is teaching a class on HIV prevention. Which of the following should be
emphasized as increasing risk?
A) Donating blood
B) Using public bathrooms
C) Unprotected sex
D) Touching a person with AIDS
Answer: C
60. The charge nurse is planning assignments on a medical unit. Which client should be
assigned to the unlicensed assistive personnel (UAP)? A client with
A) Difficulty swallowing after a mild stroke
B) an order of enemas until clear prior to colonoscopy
C) an order for a post-op abdominal dressing change
D) transfer orders to a long term facility
Answer: B
61. A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds
that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small
teeth with faulty enamel. The mother states: ”My child seems to have problems in learning to
count and recognizing basic colors.” Based on this data, the nurse suspects that the child is
most likely showing the effects of which problem?
A) Congenital abnormalities
B) Chronic toxoplasmosis
C) Fetal alcohol Syndrome
D) Lead poisoning
Answer: C
62. The nurse has performed the initial assessments of 4 clients admitted with an acute episode
of asthma. Which assessment finding would cause the nurse to call the healthcare provider
immediately?
A) Prolonged inspiration with each breath
B) Expiratory wheezes that are suddenly absent in one lobe
C) Expectoration of large amounts of purulent mucous
D) Appearance of the use of abdominal muscles for breathing
Answer: B
63. The nurse is planning a meal plan that would provide the most iron for a child with anemia.
Which dinner menu would be best?
A) Fish sticks, French fries, banana, cookies, milk
B) Ground beef patty, lima beans, wheat roll, raisins, milk
C) Chicken nuggets, macaroni, peas, cantaloupe, milk
D) Peanut butter and jelly sandwich, apple slices, milk
Answer: B
64. A 10 year-old client is recovering from a splenectomy following a traumatic injury. The
clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The
best approach for the nurse to use is to
A) Limit milk and milk products
B) Encourage bed activities and games
C) Plan nursing care around lengthy rest periods
D) Promote a diet rich in iron
Answer: C
65. The nurse planning care for a 12 year-old child with sickle cell disease in a vaso- occlusive
crisis of the elbow should include which one of the following as a priority?
A) Limit fluids
B) Client controlled analgesia
C) Cold compresses to elbow
D) Passive range of motion exercise
Answer: B
66. As the nurse provides discharge teaching to the parents of a 15 month-old child with
Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would
be appropriate?
A) High doses of aspirin will be continued for some time
B) Complete recovery is expected within several days
C) Active range of motion exercises should be done frequently
D) The measles, mumps and rubella vaccine should be delayed
Answer: D
67. The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse
would emphasize that pancreatic enzymes should be taken
A) Once each day
B) 3 times daily after meals
C) With each meal or snack
D) Each time carbohydrates are eaten
Answer: C
68. The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal
shunt. Which one of the following manifestations would the infant be most likely to exhibit?
A) Lethargy
B) Irritability
C) Negative Moro
D) Depressed fontanel
Answer: B
69. The nurse is performing a physical assessment on a toddler. Which of the following should
be the first action?
A) Perform traumatic procedures
B) Use minimal physical contact
C) Proceed from head to toe
D) Explain the exam in detail
Answer: B
70. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of
these findings noted on the initial nursing assessment requires quick intervention by the nurse?
A) A report of 10 pounds weight loss in the last month
B) A comment by the client "I just can't sit still."
C) The appearance of eyeballs that appear to "pop" out of the client's eye sockets
D) A report of the sudden onset of irritability in the past 2 weeks
Answer: C
71. Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate
action is required?
A) pH below 7.3
B) Potassium of 5.0
C) HCT of 60
D) Pa O2 of 79%
Answer: C
72. The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The
nurse plans to explain proper communication in the event of accidental poisoning. The nurse
should plan to tell the parents to first state what substance was ingested and then what
information should be the priority for the parents to communicate?
A) The parents' name and telephone number
B) The currency of the immunization and allergy history of the child
C) The estimated time of the accidental poisoning and a confirmation that the parents will
bring the containers of the ingested substance
D) The affected child's age and weight
Answer: D
73. A 2 year-old child is brought to the health care provider's office with a chief complaint of
mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?
A) Place the child on clear liquids and gelatin for 24 hours
B) Continue with the regular diet and include oral rehydration fluids
C) Give bananas, apples, rice and toast as tolerated
D) Place NPO for 24 hours, then rehydrate with milk and water
Answer: B
74. The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is
concerned that the client is unable to coordinate the release of the medication with the
inhalation phase. What is the nurse's best recommendation to improve delivery of the
medication?
A) Nebulized treatments for home care
B) Adding a spacer device to the MDI canister
C) Asking a family member to assist the client with the MDI
D) Request a visiting nurse to follow the client at home
Answer: B
75. Which of the following manifestations observed by the school nurse confirms the presence
of pediculosis capitis in students?
A) Scratching the head more than usual
B) Flakes evident on a student's shoulders
C) Oval pattern occipital hair loss
D) Whitish oval specks sticking to the hair
Answer: D
76. When parents call the emergency room to report that a toddler has swallowed drain cleaner,
the nurse instructs them to call for emergency transport to the hospital. While waiting for an
ambulance, the nurse would suggest for the parents to give sips of which substance?
A) Tea
B) Water
C) Milk
D) Soda
Answer: B
77. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data
from the client’s history indicate a potential hazard for this test?
A) Reflex incontinence
B) Allergic to shellfish
C) Claustrophobia
D) Hypertension
Answer: B
78. The nurse is preparing a handout on infant feeding to be distributed to families visiting the
clinic. Which notation should be included in the teaching materials?
A) Solid foods are introduced 1 at a time beginning with cereal
B) Finely ground meat should be started early to provide iron
C) Egg white is added early to increase protein intake
D) Solid foods should be mixed with formula in a bottle
Answer: A
79. The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of
packed red blood cells. Which of the following is an appropriate action for the nurse when
administering the infusion?
A) Storing the packed red cells in the medicine refrigerator while starting IV
B) Slow the rate of infusion if the client develops fever or chills
C) Limit the infusion time of each of the unit to a maximum of 4 hours
D) Assess vital signs every 15 minutes throughout the entire infusion
Answer: C
80. A client with a documented pulmonary embolism has the following arterial blood gases:
PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on this data,
what is the first nursing action?
A) Review other lab data
B) Notify the health care provider
C) Administer oxygen
D) Calm the client
Answer: C
81. A client diagnosed with hepatitis C discusses his health history with the admitting nurse.
The nurse should recognize which statement by the client as the most important?
A) I got back from Central America a few weeks ago.
B) I had the best raw oysters last week.
C) I have many different sex partners.
D) I had a blood transfusion 15 years ago.
Answer: D
82. A client is recovering from a thyroidectomy. While monitoring the client's initial post
operative condition, which of the following should the nurse report immediately?
A) Tetany and paresthesia
B) Mild stridor and hoarseness
C) Irritability and insomnia
D) Headache and nausea
Answer: A
83. A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most
appropriate action by the nurse to protect the self would be which of these?
A) Negative room ventilation
B) Face mask with shield
C) Particulate respirator mask
D) Airborne precautions
Answer: C
84. A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the
nurse to include at the change of shift report?
A) The client lost 2 pounds in 24 hours
B) The client’s potassium level is 4 mEq/liter.
C) The client’s urine output was 1500 cc in 5 hours
D) The client is to receive another dose of Lasix at 10 PM
Answer: C
85. The nurse is caring for a client with a colostomy. During a teaching session, the nurse
recommends that the pouch be emptied
A) When it is 1/3 to 1/2 full
B) Prior to meals
C) After each fecal elimination
D) At the same time each day
Answer: A
86. Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which
of the following assessments would the nurse use to evaluate the effectiveness of this
treatment?
A) An increase in appetite
B) A decrease in fluid retention
C) A decrease in lethargy
D) A reduction in jaundice
Answer: C
87. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to
whole milk and add cereal and meats to the diet. What should be emphasized as the nurse
teaches about infant nutrition?
A) Solid foods should be introduced at 3-4 months
B) Whole milk is difficult for a young infant to Digest
C) Fluoridated tap water should be used to dilute milk
D) Supplemental apple juice can be used between feedings
Answer: B
88. The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery.
Which of the following information would indicate that the client is at risk for thrombus
formation in the post-operative period?
A) Estrogen replacement therapy
B) 10% less than ideal body weight
C) Hypersensitivity to heparin
D) History of hepatitis
Answer: A
89. The nurse is planning discharge for a 90 year-old client with musculoskeletal weakness.
Which intervention should be included in the plan and would be most effective for the
prevention of falls?
A) Place nightlight in the bedroom
B) Wear eyeglasses at all times
C) Install grab bars in the bathroom
D) Teach muscle strengthening exercises
Answer: A
90. An 8 year-old client is admitted to the hospital for surgery. The child’s parent reports the
following allergies. Of these allergies which one should all health care personnel be aware of?
A) Shellfish
B) Molds
C) Balloons
D) Perfumed soap
Answer: C
91. The nurse is caring for a client who is post-op following a thoracotomy. The client has 2
chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in
the waterseal chamber when the client coughs. What is the most appropriate nursing action?
A) Clamp the chest tube
B) Call the surgeon immediately
C) Continue to monitor the client to see if the bubbling increases
D) Instruct the client to try to avoid coughing
Answer: C
92. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for
a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the
client?
A) Complete the entire course of the medication for an effective cure
B) Begin treatment with acyclovir at the onset of symptoms of recurrence
C) Stop treatment if she thinks she may be pregnant to prevent birth defects
D) Continue to take prophylactic doses for at least 5 years after the diagnosis
Answer: B
93. An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic
syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice?
A) Bologna sandwich, pudding, milk
B) Frankfurter, baked potato, milk
C) Chicken strips, corn on the cob, milk
D) Grilled cheese sandwich, apple, milk
Answer: C
94. The nurse is teaching parents about accidental poisoning in children. Which point should
be emphasized?
A) Call the Poison Control Center once the situation is identified
B) Empty the child's mouth in any case of possible poisoning
C) Have the child move minimally if a toxic substance was inhaled
D) Do not induce vomiting if the poison is a hydrocarbon
Answer: B
95. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant
withholding the dose?
A) Drowsiness, lethargy, and inactivity
B) Dry mouth, nasal congestion, and blurred vision
C) Rash, blood dyscrasias, severe depression
D) Hyperglycemia, weight gain, and edema
Answer: C
96. The nurse is planning care for a 14 year-old client returning from scoliosis corrective
surgery. Which of the following actions should receive priority in the plan?
A) Antibiotic therapy for 10 days
B) Teach client isometric exercises for legs
C) Assess movement and sensation of extremities
D) Assist to stand up at bedside within the first 24 hours
Answer: C
97. A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of
the following would be an appropriate snack?
A) Cheese crackers
B) Peanut butter sandwich
C) Potato chips
D) Vanilla cookies
Answer: C
98. A client with moderate persistent asthma is admitted for a minor surgical procedure. On
admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is
complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should
the nurse do first?
A) Notify the health care provider
B) Administer the PRN dose of Albuterol
C) Apply oxygen at 2 liters per nasal cannula
D) Repeat the peak flow reading in 30 minutes
Answer: B
99. What finding signifies that children have attained the stage of concrete operations (Piaget)?
A) Explores the environment with the use of sight and movement
B) Thinks in mental images or word pictures
C) Makes the moral judgement that "stealing is wrong"
D) Reasons that homework is time-consuming yet necessary
Answer: C
100. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the
following lab reports should the nurse review first?
A) Prothrombin time (PT) and partial thromboplastin time (PTT)
B) Red blood cell and white blood cell counts
C) Blood urea nitrogen and creatinine clearance
D) Liver enzymes (AST and ALT)
Answer: D
101. The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and
mild dehydration. In addition to oral rehydration fluids, the diet should include
A) Formula or breast milk
B) Broth and tea
C) Rice cereal and apple juice
D) Gelatin and ginger ale
Answer: A
102. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or
milk. What is the physiological basis for this instruction?
A) Retards pepsin production
B) Stimulates hydrochloric acid production
C) Slows stomach emptying time
D) Decreases production of hydrochloric acid
Answer: B
103. The nurse is planning care for a 3 month-old infant immediately postoperative following
placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to
A) Assess for abdominal distention
B) Maintain infant in an upright position
C) Begin formula feedings when infant is alert
D) Pump the shunt to assess for proper function
Answer: A
104. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's
screaming every time the mother gets ready to leave the hospital room. What is the best
response by the nurse?
A) "I think you or your partner needs to stay with the child while in the hospital."
B) "Oh, that behavior will stop in a few days."
C) "Keep in mind that for the age this is a normal response to being in the hospital."
D) "You might want to "sneak out" of the room once the child falls asleep."
Answer: C
105. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the
nurse monitor to determine therapeutic response to the drug?
A) Bleeding time
B) Coagulation time
C) Prothrombin time
D) Partial thromboplastin time
Answer: C
106. The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy.
Which of the following assessments must be reported immediately?
A) Vomiting of dark emesis
B) Complaints of throat pain
C) Apical heart rate of 110
D) Increased restlessness
Answer: D
107. The nurse admits a 7 year-old to the emergency room after a leg injury. The xrays show a
femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The
appropriate response by the nurse should be which of these statements?
A) "The injury is expected to heal quickly because of thin periosteum."
B) "In some instances, the result is a retarded bone growth."
C) "Bone growth is stimulated in the affected leg."
D) "This type of injury shows more rapid union than that of younger children."
Answer: B
108. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a
home visit the nurse observes the client smacking her lips alternately with grinding her teeth.
The nurse recognizes this assessment finding as what?
A) Dystonia
B) Akathesia
C) Brady dyskinesia
D) Tardive dyskinesia
Answer: D
109. During the checkup of a 2 month-old infant at a well-baby clinic, the mother expresses
concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not
gone away. What is an appropriate response by the nurse?
A) "Mongolian spots are a normal finding in dark-skinned children."
B) "Port wine stains are often associated with other malformations."
C) "Telangiectatic nevi are normal and will disappear as the baby grows."
D) "The child is too young for consideration of surgical removal of these at this time."
Answer: C
110. A client has returned to the unit following a renal biopsy. Which of the following nursing
interventions is appropriate?
A) Ambulate the client 4 hours after procedure
B) Maintain client on NPO status for 24 hours
C) Monitor vital signs
D) Change dressing every 8 hours
Answer: C
111. A client has been admitted with a fractured femur and has been placed in skeletal traction.
Which of the following nursing interventions should receive priority?
A) Maintaining proper body alignment
B) Frequent neurovascular assessments of the affected leg
C) Inspection of pin sites for evidence of drainage or inflammation
D) Applying an over-bed trapeze to assist the client with movement in bed
Answer: B
112. The nurse is teaching a client newly diagnosed with asthma how to use the metered dose
inhaler (MDI). The client asks when they will know the canister is empty. The best response is
A) Drop the canister in water to observe floating
B) Estimate how many doses are usually in the canister
C) Count the number of doses as the inhaler is used
D) Shake the canister to detect any fluid movement
Answer: A
113. While teaching the family of a child who will take phenytoin (Dilantin) regularly for
seizure control, it is most important for the nurse to teach them about which of the following
actions?
A) Maintain good oral hygiene and dental care
B) Omit medication if the child is seizure free
C) Administer acetaminophen to promote sleep
D) Serve a diet that is high in iron
Answer: A
114. A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over
several hours. The nurse should prepare the client for an immediate
A) Non stress test
B) Abdominal ultrasound
C) Pelvic exam
D) X-ray of abdomen
Answer: B
115. The nurse is assessing a 17 year-old female client with bulimia. Which of the following
laboratory reports would the nurse anticipate?
A) Increased serum glucose
B) Decreased albumin
C) Decreased potassium
D) Increased sodium retention
Answer: C
116. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps
and halo vision. Which of the following laboratory results should the nurse analyze first?
A) Potassium levels
B) Blood pH
C) Magnesium levels
D) Blood urea nitrogen
Answer: A
117. The nurse caring for a 9 year-old child with a fractured femur is told that a medication
error occurred. The child received twice the ordered dose of morphine an hour ago. Which
nursing diagnosis is a priority at this time?
A) Risk for fluid volume deficit related to morphine overdose
B) Decreased gastrointestinal mobility related to mucosal irritation
C) Ineffective breathing patterns related to central nervous system depression
D) Altered nutrition related to inability to control nausea and vomiting
Answer: C
118. The nurse notes that a 2 year-old child recovering from a tonsillectomy has an
temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's mother reports
that the child "feels very warm" to touch. The first action by the nurse should be to
A) Reassure the mother that this is normal
B) Offer the child cold oral fluids
C) Reassess the child's temperature
D) Administer the prescribed acetaminophen
Answer: C
119. The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter.
The nurse explains that this should be used to
A) Determine oxygen saturation
B) Measure forced expiratory volume
C) Monitor atmosphere for presence of allergens
D) Provide metered doses for inhaled bronchodilator
Answer: B
120. The nurse is performing a pre-kindergarten physical on a 5 year old. The last series of
vaccines will be administered. What is the preferred site for injection by the nurse?
A) Vastus intermedius
B) Gluteus rainlinus
C) Vastus lateralis
D) DorsogluteaI
Answer: C
121. A couple experienced the loss of a 7 month-old fetus. In planning for discharge, what
should the nurse emphasize?
A) To discuss feelings with each other and use support persons
B) To focus on the other healthy children and move through the loss
C) To seek causes for the fetal death and come to some safe conclusion
D) To plan for another pregnancy within 2 years and maintain physical health
Answer: A
122. The parents of a 4 year-old hospitalized child tell the nurse, “We are leaving now and will
be back at 6 PM.” A few hours later the child asks the nurse when the parents will come again.
What is the best response by the nurse?
A) "They will be back right after supper."
B) "In about 2 hours, you will see them."
C) "After you play awhile, they will be here."
D) "When the clock hands are on 6 and 12."
Answer: A
123. The nurse is providing instructions for a client with asthma. Which of the following
should the client monitor on a daily basis?
A) Respiratory rate
B) Peak air flow volumes
C) Pulse oximetry
D) Skin color
Answer: B
124. Therapeutic nurse-client interaction occurs when the nurse
A) Assists the client to clarify the meaning of what the client has said
B) Interprets the client’s covert communication
C) Praises the client for appropriate feelings and behavior
D) Advises the client on ways to resolve problems
Answer: A
125. A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following
would the nurse expect to see in the child?
A) Hypothermia
B) Edema
C) Dyspnea
D) Epistaxis
Answer: D
126. The nurse is caring for a client with a distal tibia fracture. The client has had a closed
reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly
becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The
first assessment the nurse should perform is
A) Orientation to time, place and person
B) Pulse oximetry
C) Circulation to casted extremity
D) Blood pressure
Answer: B
127. Which nursing intervention will be most effective in helping a withdrawn client to
develop relationship skills?
A) Offer the client frequent opportunities to interact with 1 person
B) Provide the client with frequent opportunities to interact with other clients
C) Assist the client to analyze the meaning of the withdrawn behavior
D) Discuss with the client the focus that other clients have similar problems
Answer: A
128. The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following
treatments are most effective to promote healing?
A) Covering the wound with a dry dressing
B) Using hydrogen peroxide soaks
C) Leaving the area open to dry
D) Applying a hydrocolloid or foam dressing
Answer: D
129. A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this
turns out to be cancer and I have to have my breast removed, my partner will never come near
me." The nurse's best response would be which of these statements?
A) "I hear you saying that you have a fear for the loss of love."
B) "You sound concerned that your partner will reject you."
C) "Are you wondering about the effects on your sexuality?"
D) "Are you worried that the surgery will change you?"
Answer: D
130. When teaching suicide prevention to the parents of a 15 year-old who recently attempted
suicide, the nurse describes the following behavioral cue
A) Angry outbursts at significant others
B) Fear of being left alone
C) Giving away valued personal items
D) Experiencing the loss of a boyfriend
Answer: C
131. The nurse is caring for a 4 year-old admitted after receiving burns to more than 50% of
his body. Which laboratory data should be reviewed by the nurse as a priority in the first 24
hours?
A) Blood urea nitrogen
B) Hematocrit
C) Blood glucose
D) White blood count
Answer: A
132. The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days
ago. The client has many questions about this condition. What area is a priority for the nurse to
discuss at this time?
A) Daily needs and concerns
B) The overview cardiac rehabilitation
C) Medication and diet guideline
D) Activity and rest guidelines
Answer: A
133. The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler
evaluation. Which of the following would be necessary for preparing the client for this test?
A) Client should be NPO after midnight
B) Client should receive a sedative medication prior to the test
C) Discontinue anti-coagulant therapy prior to the test
D) No special preparation is necessary
Answer: D
134. While interviewing a client, the nurse notices that the client is shifting positions, wringing
her hands and avoiding eye contact. It is important for the nurse to
A) Ask the client what she is feeling
B) Assess the client for auditory hallucinations
C) Recognize the behavior as a side effect of medication
D) Re-focus the discussion on a less anxiety provoking topic
Answer: A
135. Which statement made by a client indicates to the nurse that he may have a thought
disorder?
A) "I'm so angry about this. Wait until my partner hears about this."
B) "I'm a little confused. What time is it?"
C) "I can't find my “Mesmer” shoes. Have you seen them?"
D) "I'm fine. It's my daughter who has the problem."
Answer: C
136. The nurse is observing a client with an obsessive-compulsive disorder in an inpatient
setting. Which behavior is consistent with this diagnosis?
A) Repeatedly checking that the door is locked
B) Verbalized suspicions about thefts
C) Preference for consistent care givers
D) Repetitive, involuntary movements
Answer: A
137. A young adult seeks treatment in an outpatient mental health center. The client tells the
nurse he is a government official being followed by spies. On further questioning, he reveals
that his warnings must be heeded to prevent nuclear war. What is the most therapeutic
approach by the nurse?
A) Listen quietly without comment
B) Ask for further information on the spies
C) Confront the client on a delusion
D) Contact the government agency
Answer: A
138. A client is admitted to a psychiatric unit with delusions. What findings can the nurse
expect?
A) Flight of ideas and hyperactivity
B) Suspiciousness and resistance to therapy
C) Anorexia and hopelessness
D) Panic and multiple physical complaints
Answer: B
139. A client who is a former actress enters the day room wearing a sheer nightgown, high
heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action
is the best in response to the client’s attire?
A) Gently remind her that she is no longer on stage
B) Directly assist client to her room for appropriate apparel
C) Quietly point out to her the dress of other clients on the unit
D) Tactfully explain appropriate clothing for the hospital
Answer: B
140. Handshaking is the preferred form of touch or contact used with clients in a psychiatric
setting. The rationale behind this limited touch practice is that
A) Some clients misconstrue hugs as an invitation to sexual advances
B) Handshaking keeps the gesture on a professional level
C) Refusal to touch a client denotes lack of concern
D) Inappropriate touch often results in charges of assault and battery
Answer: A
141. A client with paranoid delusions stares at the nurse over a period of several days. The
client suddenly walks up to the nurse and shouts "You think you’re so perfect and pure and
good." An appropriate response for the nurse is
A) "Is that why you’ve been staring at me?"
B) "You seem to be in a really bad mood."
C) "Perfect? I don’t quite understand."
D) "You are angry right now."
Answer: D
142. An important goal in the development of a therapeutic inpatient milieu is to
A) Provide a businesslike atmosphere where clients can work on individual goals
B) Provide a group forum in which clients decide on unit rules, regulations, and policies
C) Provide a testing ground for new patterns of behavior while the client takes responsibility
for his or her own actions
D) Discourage expressions of anger because they can be disruptive to other clients
Answer: C
143. The nurse's primary intervention for a client who is experiencing a panic attack is to
A) Develop a trusting relationship
B) Assist the client to describe his experience in detail
C) Maintain safety for the client
D) Teach the client to control his or her own behavior
Answer: C
144. Which intervention best demonstrates the nurse's sensitivity to a 16 year old’s appropriate
need for autonomy?
A) Alertness for feelings regarding body image
B) Allows young siblings to visit
C) Provides opportunity to discuss concerns without presence of parents
D) Explores his feelings of resentment to identify causes
Answer: C
145. A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and
cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe
are
A) Brittle hair, lanugo, amenorrhea
B) Diarrhea, nausea, vomiting, dental erosion
C) Hyperthermia, tachycardia, increased metabolic rate
D) Excessive anxiety about symptoms
Answer: A
146. A depressed client in an assisted living facility tells the nurse that "life isn't worth living
anymore." What is the best response to this statement?
A) "Come on, it is not that bad."
B) "Have you thought about hurting yourself?"
C) "Did you tell that to your family?"
D) "Think of the many positive things in life."
Answer: B
147. A client, recovering from alcoholism, asks the nurse, "What can I do when I start
recognizing relapse triggers within myself?" How might the nurse best respond?
A) "When you have the impulse to stop in a bar, contact a sober friend and talk with him."
B) "Go to an AA meeting when you feel the urge to drink."
C) "It is important to exercise daily and get involved in activities that will cause you not to
think about drug use."
D) "Identify your relapse triggers as part of getting better."
Answer: D
148. A client was admitted to the eating disorder unit with bulimia nervosa. The nurse
assessing for a history of complications of this disorder expects
A) Respiratory distress, dyspnea
B) Bacterial gastrointestinal infections, over hydration
C) Metabolic acidosis, constricted colon
D) Dental erosion, parotid gland enlargement
Answer: D
149. A nurse entering the room of a postpartum mother observes the baby lying at the edge of
the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not
want it." The nurse's best response is
A) ”This is a common occurrence after birth, but you will come to accept the baby."
B) ”Many women have postpartum blues and need some time to love the baby."
C) ”What a beautiful baby! Her eyes are just like yours."
D) ”You seem upset; tell me what the pregnancy and birth were like for you."
Answer: D
150. Which of the following times is a depressed client at highest risk for attempting suicide?
A) Immediately after admission, during one-to-one observation
B) 7 to 14 days after initiation of antidepressant medication and psychotherapy
C) Following an angry outburst with family
D) When the client is removed from the security room
Answer: B
151. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss
the problem. What information is most important for the nurse to ask about at this time?
A) What are you taking for pain and does it provide total relief?
B) What does the skin on the testicles look and feel like?
C) Do you have any questions about your care?
D) Did you know a consequence of epididymitis is infertility?
Answer: B
152. A client has had heart failure. Which intervention is most important for the nurse to
implement prior to the initial administration of Digoxin to this client?
A) Assess the apical pulse, counting for a full 60 seconds
B) Take a radial pulse, counting for a full 60 seconds
C) Use the pulse reading from the electronic blood pressure device
D) Check for a pulse deficit
Answer: A
153. A client is admitted with a tentative diagnosis of congestive heart failure. Which of the
following assessments would the nurse expect to be consistent with this problem?
A) Chest pain
B) Pallor
C) Inspiratory crackles
D) Heart murmur
Answer: C
154. A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU)
after an emergency appendectomy. Which finding is an early indication that the client is
experiencing poor oxygenation?
A) Abnormal breath sounds
B) Cyanosis of the lips
C) Increasing pulse Rate
D) Pulse oximeter reading of 92%
Answer: C
155. Which order can be associated with the prevention of atelectasis and pneumonia in a
client with amyotrophic lateral sclerosis?
A) Active and passive range of motion exercises twice a day
B) Every 4 hours incentive spirometer
C) Chest physiotherapy twice a day
D) Repositioning every 2 hours around the clock
Answer: C
156. A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and
hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a fractured
lower right leg 1 hour ago reports that the pain is getting worse. The nurse should recognize
that the client may be developing which complication?
A) Acute compartment syndrome
B) Thromboembolic complications
C) Fatty embolism
D) Osteomyelitis
Answer: A
157. The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement
from the mother supports the presence of this problem?
A) When I put my finger in the left hand the baby doesn’t respond with a grasp.
B) My baby doesn’t seem to follow when I shake toys in front of the face.
C) When it thundered loudly last night the baby didn’t even jump.
D) When I put the baby in a back lying position that’s how I find the baby.
Answer: D
158. Which statements by the client would indicate to the nurse an understanding of the issues
with end stage renal disease?
A) I have to go at intervals for epoetin (Procrit) injections at the health department.
B) I know I have a high risk of clot formation since my blood is thick from too many red cells.
C) I expect to have periods of little water with voiding and then sometimes to have a lot of
water.
D) My bones will be stronger with this disease since I will have higher calcium than normal.
Answer: A
159. The nurse is caring for a client with uncontrolled hypertension. Which findings require
priority nursing action?
A) Lower extremity pitting edema
B) Rales
C) Jugular vein distension
D) Weakness in left arm
Answer: D
160. A 2 year-old child is brought to the emergency department at 2:00 in the afternoon. The
mother states: “My child has not had a wet diaper all day.” The nurse finds the child is pale
with a heart rate of 132. What assessment data should the nurse obtain next?
A) Status of the eyes and the tongue
B) Description of play activity
C) History of fluid intake
D) Dietary patterns
Answer: A
