HESI EXIT RN 2022 V3 160 Questions
1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric
tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour after admission to
the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart rate is 155 beats/minute,
and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action
should the nurse implement first?
A. Measure and document the client’s urinary output.
B. Request the client’s reserved unit if packed red blood cells.
C. Prepare the placement of a central venous catheter.
D. Increase the infusion rate of Lactated Ringer’s solution.
Answer: D. Increase the infusion rate of Lactated Ringer’s solution.
2. An adult male who fell 20 feet from the roof of this home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive
care unit (ICU). the nurse notes that the suction control chamber is bubbling at the - 10 cm H2O mark,
with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the
collection chamber. Which intervention should the nurse implement?
A. Add sterile water to the suction control chamber.
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into chamber.
D. Increase wall suction to eliminate fluctuation in water seal.
Answer: A. Add sterile water to the suction control chamber.
3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart
rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath,
bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse
take first?
A. Elevate the foot of the bed.
B. Restrict the client’s fluid.
C. Begin supplemental oxygen.
D. Prepare the client for hemodialysis.
Answer: C. Begin supplemental oxygen.
4. A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation.
Based on the client’s admitting diagnosis, which findings require immediate action by the nurse? (Select
all that apply)
A. Headache and tremors
B. Irregular heart rate
C. Skin hyperpigmentation
D. Postural hypotension
E. Pallor and diaphoresis
Answer: A. Headache and tremors
B. Irregular heart rate
E. Pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the
best indicator of hydration that the nurse should report to the healthcare provider?
A. Urine specific gravity is 1.040
B. Systolic blood pressure decreases 10 points when standing.
C. The client denies being thirsty.
D. Skin tenting occurs when the client’s forearm is pinched.
Answer: D. Skin tenting occurs when the client’s forearm is pinched.
6. After an inservice about electronic health record (EHR) security and safeguarding client information,
the nurse observes a colleague going home with printed copies of client information in a uniform pocket.
Which action should the nurse take?
A. File a detailed incident report with the specific hiring facility.
B. Warn the colleague that their actions are unprofessional.
C. Comment anonymously about the action of a staff discussion board.
D. Communicate the colleague’s actions to the unit charge nurse.
Answer: A. File a detailed incident report with the specific hiring facility.
7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease
implemented in a rural health clinic. Which outcome indicate the program is effective?
A. At-risk clients received an increased number of routine health screenings.
B. Clients reported having new confidence in making healthy food choices.
C. Clients who incurred disease complications promptly received rehabilitation.
D. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
Answer: C. Clients who incurred disease complications promptly received rehabilitation.
8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at
2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness
of breath with respirations at 23 breaths/minute. Which action should the nurse implement first?
A. Determine if the client is experiencing any anxiety.
B. Auscultate the client’s bilateral lung sounds and oxygen saturation.
C. Notify the healthcare provider about the client’s distress.
D. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
Answer: D. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate
investigation by the nurse?
A. “When I get out of bed quickly, I feel a little dizzy.”
B. “The dressing over my incision feels like it is too tight.”
C. “I’m most comfortable when the head of the bed is raised.”
D. “This IV infusion makes me urinate more often than usual.”
Answer: A. “When I get out of bed quickly, I feel a little dizzy.”
10. An older adult male who is in his early 70’s is admitted to the emergency department because of a
COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for
endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the nurse to stop
the procedure and provide the nurse a copy of the client’s living will. Which action should the nurse take?
A. Facilitate a family meeting with the palliative care team.
B. Notify the healthcare provider of the client’s wishes.
C. Place a certified copy of the living will in the client’s record.
D. Alert the nursing staff of the client’s don’t resuscitate status.
Answer: B. Notify the healthcare provider of the client’s wishes.
11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so
obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside
commode. How should the nurse respond?
A. Determine the client’s level of mobility and need for assistance.
B. Instruct the UAP that all clients deserve equal care.
C. Advice the client to maintain bedrest so that safety can be ensured.
D. Assign another UAP to care for the client.
Answer: C. Advice the client to maintain bedrest so that safety can be ensured.
12. A nurse determines that more than 25% of the students at a middle school are overweight. The nurse
presents the information at the parent-teacher meeting. What action is most important for the nurse to
include in the meeting?
A. Provide information on ways to increase activity for the family.
B. Have several teachers talk about health risks associated with obesity.
C. Distribute a shopping list of suggested healthy snack items.
D. Determine the parents’ degree of concern about their children’s weight.
Answer: C. Distribute a shopping list of suggested healthy snack items.
13. After several months of chronic fatigue, morning stiffness, and join pain, a young adult is diagnosed
with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the
nurse provide the client with regard to taking prednisone?
A. Take prednisone doses before meals on an empty stomach.
B. Wear sunglasses when exposed to bright sunlight.
C. If sequential doses are missed, notify the healthcare provider.
D. Schedule a monthly laboratory visit for a complete blood count.
Answer: C. If sequential doses are missed, notify the healthcare provider.
14. The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse’s
immediate attention?
A. A 16-year-old client diagnosed with major depression who refuses to participate in group.
B. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.
C. An 18-year-old client with antisocial behavior who is being yelled at by other clients
D. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby.
Answer: C. An 18-year-old client with antisocial behavior who is being yelled at by other clients
15. The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?
A. Positive Epstein-Barr, and malaise.
B. Ear pain and fever.
C. Elevated WBC and sedimentation rate.
D. Increased BUN and serum creatinine.
Answer: B. Ear pain and fever.
16. A client arrives for an annual physical exam and complains of having calf pain. The client’s health
history reveals peripheral atrial disease. Which question should the nurse ask the client about expected
finding related to chronic arterial symptoms?
A. Were your legs ever suddenly swollen, red, warm, and painful?
B. Does the calf pain occur when walking short distances?
C. Did you receive treatment for weeping ulcers on lower legs?
D. Have you experienced ankle edema and varicose veins?
Answer: B. Does the calf pain occur when walking short distances?
17. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which
client report is most important for them to explore further prior to the start of the procedure?
A. Drank a glass of water in the past 2 hours.
B. Reports left chest wall pain prior to admission.
C. Verbalize a fear of being in a confined space.
D. Experience facial swelling after eating crab.
Answer: D. Experience facial swelling after eating crab.
18. The nurse is assessing a 4-year-old child with eczema. The child’s skin is dry and scaly, and the mother
reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which
guideline is indicated for care of this child?
A. Keep the nails trimmed short.
B. Apply baby lotion to the skin twice daily.
C. Bathe the child daily with bath oil.
D. Allow the child to wear only 100% cotton clothing.
Answer: B. Apply baby lotion to the skin twice daily.
19. A new mother on the postpartum unit runs out of the room screaming that her newborn infant’s crib is
empty and the baby is missing. What action should the nurse take first?
A. Determine if the newborn is in the nursery.
B. Activate the lockdown procedure.
C. Ask the mother if any visitors were expected to arrive.
D. Match ID bands of all infants and mothers on the unit.
Answer: D. Match ID bands of all infants and mothers on the unit.
20. While providing a health history, a female client tells the clinic nurse that she frequently thinks about
hurting herself. Which question is most important for the nurse to ask?
A. “Do you often have feeling of sadness?”
B. “Are you having problems concentrating?”
C. “Have you though about taking your life?”
D. “What problems are you facing right now?”
Answer: C. “Have you though about taking your life?”
21. A college student brings a dorm roommate to the campus clinic because the roommate has been talking
to someone who is not present. The client tells the nurse that the voices are saying, “kill, kill.” What
question should the nurse ask the client next?
A. “When did these voices begin?”
B. “Have you taken any hallucinogens?”
C. “Are you planning to obey the voices?”
D. “Do you believe the voices are real?”
Answer: C. “Are you planning to obey the voices?”
22. The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly
diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for
this client?
A. The client will express acceptance of their newly diagnosed health status.
B. The nurse will encourage the client to walk thirty minutes every day.
C. The client’s blood pressure readings will be less than 160/90 mmHg.
D. The client’s skin on the lower legs will be intact at the next clinical visit.
Answer: D. The client’s skin on the lower legs will be intact at the next clinical visit.
23. When conducting diet teaching for a client who was diagnosed with hypertension, which food should
the nurse encourage the client to eat? (select all that apply.)
A. Fruits without sauce
B. Canned soup.
C. Fresh or frozen vegetables without sauce.
D. Cottage cheese.
E. Pickled olives.
Answer: A. Fruits without sauce
C. Fresh or frozen vegetables without sauce.
24. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the
nurse that the client is experiencing a therapeutic response to the phenytoin?
A. Increased time of ambulation between periods of rest.
B. Decrease in intracranial pressure and cerebral edema.
C. Absence of seizure activity for the duration of treatment.
D. Normal electroencephalogram after drug administration.
Answer: C. Absence of seizure activity for the duration of treatment.
25. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge.
Which behaviors indicate the client understands how to maintain balance safely?
(Select all that apply)
A. Brings a heavy can close to body before lifting.
B. Locks knees while preparing food on the counter.
C. Widens stance while working near the sink.
D. Bends from the waist to pick trash off the floor.
E. Leans forward to pull a pan from a high shelf.
Answer: A. Brings a heavy can close to body before lifting.
B. Locks knees while preparing food on the counter.
26. An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological
serial assessments for the past 24 hours were within normal limits. One day after admission, the client
suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention
should the nurse implement first?
A. Document neurologic changes.
B. Reduce environmental stimuli.
C. Administer prescribed neuroleptic.
D. Review medications for interactions.
Answer: B. Reduce environmental stimuli.
27. The charge nurse in an extended care facility is organizing unit activities for the day. Which action may
be safely delegated to the practical nurse (PN)?
A. Measure the client’s body weight each morning.
B. Establish blood pressure parameters for client monitoring
C. Evaluate a staff member providing wound care.
D. Evaluate client teaching through return demonstration.
Answer: B. Establish blood pressure parameters for client monitoring
28. During shift report, the charge nurse receives notice of several problems. Which problem should the
nurse address first?
A. The census report has not been completed.
B. A client’s wife has asked to speak with the charge nurse.
C. One staff member has not reported to work.
D. A bucket of water was spilled in the hallway.
Answer: D. A bucket of water was spilled in the hallway.
29. An older adult client with chronic emphysema is admitted to the emergency room from home with
acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to
obtain during the initial interview?
A. History of smoking over the past 6 months.
B. Sleep patterns during the previous few week.
C. Activity level prior to onset of symptoms.
D. Recent compliance with prescribed medications.
Answer: D. Recent compliance with prescribed medications.
30. The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak
and begins coughing while attempting to drink through a straw. Which intervention should the nurse
implement?
A. Assess the client’s oral cavity for ulcerations.
B. Monitor the client when using a straw for liquids.
C. Teach coughing and deep breathing exercises.
D. Request thick nectar liquids for the client.
Answer: B. Monitor the client when using a straw for liquids.
31. A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What
action should the nurse implement?
A. Bring a bedside commode to the client.
B. Stand on the client’s right side as he walks.
C. Walk directly behind the client to prevent a fall.
D. Give the client a cane to hold in his right hand.
Answer: B. Stand on the client’s right side as he walks.
32. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia.
The nurse notes that in the evening this client often becomes restless, confused, and agitated.
Which intervention is most important for the nurse to implement?
A. Ask family members to remain with the client in the evening from 1700 to 2100 p.m.
B. Ensure that the client is assigned to a room close to the nurses’ station.
C. Postpone administration of nighttime medications until after 2300 p.m.
D. Administer a prescribed PRN benzodiazepine at the onset of a confused state.
Answer: B. Ensure that the client is assigned to a room close to the nurses’ station.
33. The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse
include in this client’s plan of care?
A. Ensure adequate IV and oral fluid intake.
B. Provide ice packs to major joint areas.
C. Space analgesics to prevent addiction to narcotics.
D. Re-enforce the importance of nutritional balance.
Answer: A. Ensure adequate IV and oral fluid intake.
34. The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of preeclampsia
and should be reported to the healthcare provider? (select all that apply.)
A. Blurred vision
B. Headache.
C. Lack of appetite.
D. Urinary frequency.
E. Chills and fever.
F. Swollen hands.
Answer: A. Blurred vision
B. Headache.
F. Swollen hands.
35. A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action
should the charge nurse implement?
A. Suggest the nurse use a 20-gauge needle.
B. Direct the nurse to change the IV tubing.
C. Instruct the nurse to remove the needle.
D. Prompt the nurse to apply povidone to the site.
Answer: B. Direct the nurse to change the IV tubing.
36. A client with syndrome of inappropriate antidiuretic hormone secretion (SIDH) is admitted with
hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect
the client from injury?
A. Initiate seizure precautions.
B. Assess neurological status every 8 hours.
C. Limit oral water intake.
D. Administer a hypertonic IV fluids as prescribed.
Answer: A. Initiate seizure precautions.
37. The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy
in two hours, at 0900, what nursing action is most important?
A. Confirm that the client has been NPO since midnight.
B. Review postoperative instructions with the client.
C. Offer to assist the client to the restroom to void.
D. Determine when the client last had pain medication.
Answer: A. Confirm that the client has been NPO since midnight.
38. The nurse is conducing a visual screening of a group of older adults. Which finding should the nurse
report to the healthcare provider immediately?
A. Gradual onset of continuous eye pain and blurred vision.
B. Recent change in the ability to read and drive after dark.
C. Gray-white circle around the iris of both eyes.
D. Cloudy opacity of the crystalline lens.
Answer: D. Cloudy opacity of the crystalline lens.
39. A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that
he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is
best for the nurse to implement?
A. Recommend he avoid fast food restaurants until he is familiar with his prescribed diet.
B. Advise him to take his own food with him when going to fast food restaurants with his friends.
C. Encourage him to find activities to do with his friends that do not involve eating.
D. Assist him in identifying popular fast foods that are within his meal plan for diabetes.
Answer: D. Assist him in identifying popular fast foods that are within his meal plan for diabetes.
40. A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be
allowed to die. The client states that he is tired of fighting his illness and is only continuing treatments
because his family wants him to live. Which action should the nurse take?
A. Notify the family that treatments have been discontinued.
B. Arrange a meeting with the family, physician, and client.
C. Ask the chaplain to discuss death issues with the client.
D. Request a consultation with the hospital social worker.
Answer: C. Ask the chaplain to discuss death issues with the client.
41. Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty
in breathing….. had a pulmonary embolus. What action should the nurse take first?
A. Bring the emergency crash cart to the bedside.
B. Prepare a continuous heparin infusion per protocol.
C. Provide supplemental oxygen.
D. Notify the healthcare provider.
Answer: C. Provide supplemental oxygen.
42. A client admitted with a liver abscess is scheduled for surgical evacuation and drainage of the abscess
tomorrow morning. Nursing assess …. Client’s abdominal pain has increased from 4 to 8 on a 10-point
scale in the last four hours. What is priority nursing action?
A. Notify the surgeon of increasing abdominal pain.
B. Administer the nest scheduled dose of antibiotic.
C. Encourage the client to cough and deep breath.
D. Assess for a change in the client’s bowel sounds.
Answer: A. Notify the surgeon of increasing abdominal pain.
43. A female client with chronic kidney disease and renal failure has an indwelling peritoneal catheter in
….. used for peritoneal dialysis. While bathing, the her abdominal dressing becomes wet. What action
should the nurse take?
A. Change the dressing.
B. Reinforce the dressing.
C. Flush the peritoneal dialysis catheter.
D. Scrub the catheter with povidone-iodine.
Answer: A. Change the dressing.
44. The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred
vision. Which outcome shows a plan of care for this client?
A. The client will express acceptance of his changing health status.
B. The client’s family will state signs and symptoms about the disease.
C. The nurse will demonstrate the procedure for accurate eye care.
D. The client’s daily blood pressure will be less than 140/80 mmHg this month.
Answer: C. The nurse will demonstrate the procedure for accurate eye care.
45. The nurse identifies an electrolyte imbalance, an elevated pulse rate, and a weight gain of 4.4 lbs (2 kg)
in 24 hours for a client with chronic kidney disease. What intervention should the nurse include in the plan
of care?
A. Monitor serum electrolytes daily.
B. Provide only distilled water.
C. Document abdominal girth.
D. Perform range of motion exercises.
Answer: A. Monitor serum electrolytes daily.
46. A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her
room or eat meals. In addition to patient’s safety, which short-term goal should the nurse include in the
plan of care?
A. Attends one group activity per day.
B. Sleeps at least 6 hours per night.
C. Engages in one client-to-client interaction daily.
D. Consumes 3 meals and 1500 mL of fluid per day.
Answer: D. Consumes 3 meals and 1500 mL of fluid per day.
47. Which information is a priority for the RN to reinforce to an older client after intravenous pyelogram?
A. Eat a light diet for the rest of the day
B. Rest for the next 24 hours since the preparation and the test is tiring.
C. During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days
D. Measure the urine output for the next day and immediately notify the health care provider if it should
decrease.
Answer: D. Measure the urine output for the next day and immediately notify the health care provider if it
should decrease.
48. A client has altered renal function and is being treated at home. The nurse recognizes that the most
accurate indicator of fluid balance during the weekly visits is
A. Difference in the intake and output
B. Changes in the mucous membranes
C. Skin turgor
D. Weekly weight
Answer: D. Weekly weight
49. A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for
the nurse to reinforce with the client?
A. It is a condition in which one or more tumours called gastrinomas form in the pancreas or in the upper
part of the small intestine (duodenum)
B. It is critical to report promptly to your health care provider any findings of peptic ulcers
C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to
remove any tumors
D. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the
stomach or intestine
Answer: B. It is critical to report promptly to your health care provider any findings of peptic ulcers
50. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the
client’s blood pressure is increasing. Which action should the nurse take first?
A. Check the protein level in urine
B. Have the client turn to the left side
C. Take the temperature
D. Monitor the urine output
Answer: B. Have the client turn to the left side
51. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate
is controlled at 75. Which of the following findings is cause for the most concern?
A. Diminished bowel sounds
B. Loss of appetite
C. A cold, pale lower leg
D. Tachypnea
Answer: C. A cold, pale lower leg
52. The client with infective endocarditis must be assessed frequently by the home health nurse. Which
finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to
the healthcare provider?
A. Nausea and vomiting
B. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
C. Diffuse macular rash
D. Muscle tenderness
Answer: B. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
53. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points
is most important to be reinforced by the nurse?
A. Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use
another form of contraception.
B. This procedure doesn't impede the production of male hormones or the production of sperm in the
testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate.
C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't
involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally
dissolve in seven to ten days.
D. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter
pain medication to relieve any discomfort.
Answer: A. Until the health care provider has determined that your ejaculate doesn't contain sperm,
continue to use another form of contraception.
54. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time
and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about
acupuncture?
A. Some needles go as deep as 3 inches, depending on where they're placed in the body and what the
treatment is for. The needles usually are left in for 15 to 30 minutes.
B. In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi —
are thought to cause illness.
C. The flow of life is believed to flow through major pathways or nerve clusters in your body.
D. By inserting extremely fine needles into some of the over 400 acupuncture points in various
combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms
to take over.
Answer: C. The flow of life is believed to flow through major pathways or nerve clusters in your body.
55. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a
student about Kawasaki disease is incorrect?
A. It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside
the mouth, throat and nose), skin and lymph nodes.
B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint
and abdominal pain
C. Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic
descent
D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2
weeks
Answer: C. Kawasaki disease occurs most often in boys, children younger than age 5 and children of
Hispanic descent
56. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach
the client to lie in every other hour during first 12 hours after admission?
A. Side-lying on the left with the head elevated 10 degrees
B. Side-lying on the left with the head elevated 35 degrees
C. Side-lying on the right with the head elevated 10 degrees
D. Side-lying on the right with the head elevated 35 degrees
Answer: A. Side-lying on the left with the head elevated 10 degrees
57. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral
resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health
care provider?
A. Light, pink urine
B. occasional suprapubic cramping
C. minimal drainage into the urinary collection bag
D. complaints of the feeling of pulling on the urinary catheter
Answer: C. minimal drainage into the urinary collection bag
58. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the
room in response to the call. After checking the client’s pulse and respirations, what should be the function
of the second nurse?
A. Relieve the nurse performing CPR
B. Go get the code cart
C. Participate with the compressions or breathing
D. Validate the client's advanced directive
Answer: C. Participate with the compressions or breathing
59. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure.
Which of the following would the nurse anticipate finding?
A. Decreased urinary output
B. Jugular vein distention
C. Pleural effusion
D. Bibasilar crackles
Answer: B. Jugular vein distention
60. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium
should be included in the diet because hypokalemia in combination with this medication
A. Can predispose to dysrhythmias
B. May lead to oliguria
C. May cause irritability and anxiety
D. Sometimes alters consciousness
Answer: A. Can predispose to dysrhythmias
61. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of
the following neurological signs is of most concern?
A. Flaccid paralysis
B. Pupils fixed and dilated
C. Diminished spinal reflexes
D. Reduced sensory responses
Answer: B. Pupils fixed and dilated
62. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vasoocclusive crisis. Which statements by the client would be most indicative of the etiology of this crisis?
A. “I knew this would happen. I've been eating too much red meat lately.”
B. “I really enjoyed my fishing trip yesterday. I caught 2 fish.”
C. “I have really been working hard practicing with the debate team at school.”
D. “I went to the health care provider last week for a cold and I have gotten worse.”
Answer: D. “I went to the health care provider last week for a cold and I have gotten worse.”
63. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant?
A. Hemoglobin level of 12 g/dI
B. Pale mucosa of the eyelids and lips
C. Hypoactivity
D. A heart rate between 140 to 160
Answer: B. Pale mucosa of the eyelids and lips
64. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment
in the first hour of care is
A. Heart rate
B. Pedal pulses
C. Lung sounds
D. Pupil responses
Answer: D. Pupil responses
65. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use
of patient controlled analgesia (PCA) with a pump?
A. A young adult with a history of Down's syndrome
B. A teenager who reads at a 4th grade level
C. An elderly client with numerous arthritic nodules on the hands
D. A preschooler with intermittent episodes of alertness
Answer: D. A preschooler with intermittent episodes of alertness
66. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive
(NOFTT). Upon entering the room, the nurse would expect the baby to be
A. Irritable and “colicky” with no attempts to pull to standing
B. Alert, laughing and playing with a rattle, sitting with support
C. Skin color dusky with poor skin turgor over abdomen
D. Pale, thin arms and legs, uninterested in surroundings
Answer: D. Pale, thin arms and legs, uninterested in surroundings
67. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer
would the nurse expect this group to be more interested in during the discussion?
A. Mouth sores
B. Fatigue
C. Diarrhea
D. Hair loss
Answer: D. Hair loss
68. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes
today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing
intervention is to
A. Call the health care provider immediately
B. Administer acetaminophen as ordered as this is normal at this time
C. Send blood, urine and sputum for culture
D. Increase the client's fluid intake
Answer: B. Administer acetaminophen as ordered as this is normal at this time
69. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The
nurse's priority should be
A. Cover the areas with dry sterile dressings
B. Assess for dyspnea or stridor
C. Initiate intravenous therapy
D. Administer pain medication
Answer: B. Assess for dyspnea or stridor
70. Which of these clients who call the community health clinic would the nurse ask to come in that day to
be seen by the health care provider?
A. I started my period and now my urine has turned bright red.
B. I am an diabetic and today I have been going to the bathroom every hour.
C. I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the
bathroom.
D. I went to the bathroom and my urine looked very red and it didn’t hurt when I went.
Answer: D. I went to the bathroom and my urine looked very red and it didn’t hurt when I went.
71. A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also
called leiomyomas or myomas. What statement by the woman indicates more education is needed?
A. I am one out of every 4 women that get fibroids, and of women my age – between the 30s or 40s,
fibroids occurs more frequently.
B. My fibroids are noncancerous tumors that grow slowly.
C. My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent
urination or urine retention and constipation.
D. Fibroids that cause no problems still need to be taken out.
Answer: D. Fibroids that cause no problems still need to be taken out.
72. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse
is appropriate to do next?
A. Stay with client and observe for airway obstruction
B. Collect pillows and pad the side rails of the bed
C. Place an oral airway in the mouth and suction
D. Announce a cardiac arrest, and assist with intubation
Answer: A. Stay with client and observe for airway obstruction
73. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours
ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early
indication that the client is developing a complication of labor?
A. FHT 168 beats/min
B. Temperature 100 degrees Fahrenheit.
C. Cervical dilation of 4
D. BP 138/88
Answer: A. FHT 168 beats/min
74. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the
nurse’s initial evening rounds the nurse notices a foul smell in the room. The client makes all of these
statements during their conversation. Which statement would alert the nurse to a complication?
A. “I have a sharp pain in my chest when I take a breath.”
B. “I have been coughing up foul-tasting, brown, thick sputum.”
C. “I have been sweating all day.”
D. “I feel hot off and on.”
Answer: B. “I have been coughing up foul-tasting, brown, thick sputum.”
75. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart
is most likely to reveal
A. S3 ventricular gallop
B. Apical click
C. Systolic murmur
D. Split S2
Answer: A. S3 ventricular gallop
76. Which of these observations made by the nurse during an excretory urogram indicate a complicaton?
A. The client complains of a salty taste in the mouth when the dye is injected
B. The client’s entire body turns a bright red color
C. The client states “I have a feeling of getting warm.”
D. The client gags and complains “ I am getting sick.”
Answer: B. The client’s entire body turns a bright red color
77. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube.
What is the best explanation for the nurse to provide this client?
A. “The tube will drain fluid from your chest.”
B. “The tube will remove excess air from your chest.”
C. “The tube controls the amount of air that enters your chest.”
D. “The tube will seal the hole in your lung.”
Answer: B. “The tube will remove excess air from your chest.”
78. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the
following should be reported immediately?
A. Blood urea nitrogen 50 mg/dl
B. Hemoglobin of 10.3 mg/dl
C. Venous blood pH 7.30
D. Serum potassium 6 mEq/L
Answer: D. Serum potassium 6 mEq/L
79. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of
the following would require the nurse’s immediate attention?
A. Pallor
B. Increased temperature
C. Dyspnea
D. Involuntary muscle spasms
Answer: C. Dyspnea
80. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted.
Which finding would call for immediate action by the nurse?
A. Breath sounds can be heard bilaterally
B. Mist is visible in the T-Piece
C. Pulse oximetry of 88
D. Client is unable to speak
Answer: C. Pulse oximetry of 88
81. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client
may need suctioning?
A. drowsiness
B. complaint of nausea
C. pulse rate of 92
D. restlessness
Answer: D. restlessness
82. The most effective nursing intervention to prevent atelectasis from developing in a post operative
client is to
A. Maintain adequate hydration
B. Assist client to turn, deep breathe, and cough
C. Ambulate client within 12 hours
D. Splint incision
Answer: B. Assist client to turn, deep breathe, and cough
83. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the
nurse focuses on pain management to promote
A. Relaxation and sleep
B. Deep breathing and coughing
C. Incisional healing
D. Range of motion exercises
Answer: B. Deep breathing and coughing
84. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should
the nurse take first?
A. Ask client to cough sputum into container
B. Have the client take several deep breaths
C. Provide a appropriate specimen container
D. Assist with oral hygiene
Answer: D. Assist with oral hygiene
85. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect.
Which of the following nursing assessments should be a priority?
A. Blanch nail beds for color and refill
B. Assess for post operative arrhythmias
C. Auscultate for pulmonary congestion
D. Monitor equality of peripheral pulses
Answer: B. Assess for post operative arrhythmias
86. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's
room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per
minute. What should the nurse do first?
A. Obtain a 12-lead EKG
B. Place client in high Fowler's position
C. Lower the oxygen rate
D. Take baseline vital signs
Answer: C. Lower the oxygen rate
87. A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the
right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a
pulse. What should the nurse do first?
A. Notify the health care provider
B. Readjust the traction
C. Administer the ordered PRN medication
D. Reassess the foot in fifteen minutes
Answer: A. Notify the health care provider
88. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg
dressing becomes saturated with blood. The nurse's first action should be to
A. Wrap the leg with elastic bandages
B. Apply pressure at the bleeding site
C. Reinforce the dressing and elevate the leg
D. Remove the dressings and re-dress the incision
Answer: C. Reinforce the dressing and elevate the leg
89. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer.
Which of the following should take priority in planning care?
A. Esophagitis
B. Leukopenia
C. Fatigue
D. Skin irritation
Answer: B. Leukopenia
90. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the
chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection
chamber of the chest drain. What is the most appropriate nursing action?
A. Clamp the chest tube
B. Call the surgeon immediately
C. Prepare for blood transfusion
D. Continue to monitor the rate of drainage
Answer: D. Continue to monitor the rate of drainage
91. A client has returned from a cardiac catheterization. Which one of the following assessments would
indicate the client is experiencing a complication from the procedure?
A. Increased blood pressure
B. Increased heart rate
C. Loss of pulse in the extremity
D. Decreased urine output
Answer: C. Loss of pulse in the extremity
92. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but
has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid.
Which action would be most likely to help him void?
A. Have him drink several glasses of water
B. Crede’ the bladder from the bottom to the top
C. Assist him to stand by the side of the bed to void
D. Wait 2 hours and have him try to void again
Answer: C. Assist him to stand by the side of the bed to void
93. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure
alarm goes off on the ventilator. What is the first action the nurse should perform?
A. Disconnect the client from the ventilator and use a manual resuscitation bag
B. Perform a quick assessment of the client's condition
C. Call the respiratory therapist for help
D. Press the alarm re-set button on the ventilator
Answer: B. Perform a quick assessment of the client's condition
94. The health care provider order reads “aspirate nasogastric feeding (NG) tuber every 4 hours and check
pH of aspirate.” The pH of the aspirate is 10. Which action should the nurse take?
A. Hold the tube feeding and notify the provider
B. Administer the tube feeding as scheduled
C. Irrigate the tube with diet cola soda
D. Apply intermittent suction to the feeding tube
Answer: A. Hold the tube feeding and notify the provider
95. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must
A. Apply suction for no more than 10 seconds
B. Maintain sterile technique
C. Lubricate 3 to 4 inches of the catheter tip
D. Withdraw catheter in a circular motion
Answer: A. Apply suction for no more than 10 seconds
96. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0
ml The correct action is to
A. administer the medication in 2 separate injections
B. give the medication in the dorsal gluteal site
C. call to get a smaller volume ordered
D. check with pharmacy for a liquid form of the medication skip
Answer: A. administer the medication in 2 separate injections
97. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for
this route is to
A. enhance absorption of the medication
B. ensure that the entire dose of medication is given
C. provide more even distribution of the drug
D. prevent the drug from tissue irritation Skip
Answer: D. prevent the drug from tissue irritation Skip
98. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when
evaluating for the therapeutic effectiveness of this drug?
A. diaphoresis with decreased urinary output
B. increased heart rate with increase respirations
C. improved respiratory status and increased urinary output
D. decreased chest pain and decreased blood pressure
Answer: C. improved respiratory status and increased urinary output
99. While providing home care to a client with congestive heart failure, the nurse is asked how long
diuretics must be taken. What is the nurse’s best response?
A. “As you urinate more, you will need less medication to control fluid.”
B. “You will have to take this medication for about a year.”
C. “The medication must be continued so the fluid problem is controlled.”
D. “Please talk to your health care provider about medications and treatments.”
Answer: C. “The medication must be continued so the fluid problem is controlled.”
100. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for
home, which of these findings should the nurse teach the client to report?
A. Change in libido, breast enlargement
B. Sore throat, fever
C. Abdominal pain, nausea, diarrhoea
D. Dsypnea, nasal congestion
Answer: B. Sore throat, fever
101. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In
checking the client, which finding suggests a side effect of the analgesic?
A. Bruising at the operative site
B. Elevated heart rate
C. Decreased platelet count
D. No bowel movement for 3 days Skip
Answer: D. No bowel movement for 3 days Skip
102. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely
monitor which of the following laboratory values?
A. Bleeding time
B. Platelet count
C. Activated PTT
D. Clotting time
Answer: C. Activated PTT
103. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for
the administration of feedings and medications. Which nursing action is appropriate?
A. Pulverize all medications to a powdery condition
B. Squeeze the tube before using it to break up stagnant liquids
C. Cleanse the skin around the tube daily with hydrogen peroxide
D. Flush adequately with water before and after using the tube Skip
Answer: D. Flush adequately with water before and after using the tube Skip
104. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the
following statements suggests that the teaching was effective?
A. “We will call the health care provider if the child develops acne.”
B. “Our child should brush and floss carefully after every meal.”
C. “We will skip the next dose if vomiting or fever occur.”
D. “When our child is seizure-free for 6 months, we can stop the medication.”
Answer: B. “Our child should brush and floss carefully after every meal.”
105. The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When
providing instructions about precautions with this medication, which action should the nurse stress to the
client as important?
A. Avoid chocolate and cheese
B. Take frequent naps
C. Take the medication with milk
D. Avoid walking without assistance
Answer: A. Avoid chocolate and cheese
106. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate
response by the nurse?
A. Cut the child's hair short to remove the nits
B. Apply warm soaks to the head twice daily
C. Wash the child's linen and clothing in a bleach solution
D. Application of pediculicides
Answer: D. Application of pediculicides
107. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone
(Aldactone). The nurse understands that this medication spares elimination of which element?
A. Sodium
B. Potassium
C. Phosphate
D. Albumin
Answer: B. Potassium
108. The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour
after the transfusion has begun. What is the first action the nurse should take?
A. Stop the infusion
B. Slow the rate of infusion
C. Take vital signs and observe for further deterioration
D. Administer Benadryl and continue the infusion
Answer: A. Stop the infusion
109. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?
A. Sedative hypnotics are effective analgesics
B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
C. Caffeine beverages can increase the effect of sedative hypnotics
D. Avoidance of excessive exercise and high temperature is recommended
Answer: B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
110. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the
following laboratory reports would the nurse monitor most closely?
A. Bleeding time
B. Hemoglobin and hematocrit
C. White blood cells
D. Platelets
Answer: B. Hemoglobin and hematocrit
111. A client is receiving intravenous heparin therapy. What medication should the nurse have available in
the event of an overdose of heparin?
A. Protamine
B. Amicar
C. Imferon
D. Diltiazem
Answer: A. Protamine
112. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by
the client indicates a need for further teaching?
A. “I use a sliding scale to adjust regular insulin to my sugar level.”
B. “Since my eyesight is so bad, I ask the nurse to fill several syringes.”
C. “I keep my regular insulin bottle in the refrigerator.”
D. “I always make sure to shake the NPH bottle hard to mix it well.”
Answer: D. “I always make sure to shake the NPH bottle hard to mix it well.”
113. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?
A. Orthostatic hypotension is a common side effect
B. Most antipsychotic drugs cause elevated blood pressure
C. This provides information on the amount of sodium allowed in the diet
D. It will indicate the need to institute anti parkinsonian drugs
Answer: A. Orthostatic hypotension is a common side effect
114. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity.
Which choice indicates the client understands dietary needs?
A. Three apricots
B. Medium banana
C. Naval orange
D. Baked potato
Answer: D. Baked potato
115. An 86 year-old nursing home resident who has decreased mental status is hospitalized with
pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the
client begins to cough. What should the nurse do next?
A. Add a thickening agent to the fluids
B. Check the client’s gag reflex
C. Feed the client only solid foods
D. Increase the rate of intravenous fluids
Answer: B. Check the client’s gag reflex
116. The nurse is planning care for a client with a CVA. Which of the following measures planned by the
nurse would be most effective in preventing skin breakdown?
A. Place client in the wheelchair for four hours each day
B. Pad the bony prominence
C. Reposition every two hours
D. Massage reddened bony prominence
Answer: C. Reposition every two hours
117. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk
for development of decubitus ulcers?
A. A 79 year-old malnourished client on bed rest
B. An obese client who uses a wheelchair
C. A client who had 3 incontinent diarrhoea stools
D. An 80 year-old ambulatory diabetic client
Answer: A. A 79 year-old malnourished client on bed rest
118. After a client has an enteral feeding tube inserted, the most accurate method for verification of
placement is
A. Abdominal x-ray
B. Auscultation
C. Flushing tube with saline
D. Aspiration for gastric contents
Answer: A. Abdominal x-ray
119. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important
instruction regarding exercise would be to
A. Exercise doing weight bearing activities
B. Exercise to reduce weight
C. Avoid exercise activities that increase the risk of fracture
D. Exercise to strengthen muscles and thereby protect bones
Answer: A. Exercise doing weight bearing activities
120. Which bed position is preferred for use with a client in an extended care facility on falls risk
prevention protocol?
A. All 4 side rails up, wheels locked, bed closest to door
B. Lower side rails up, bed facing doorway
C. Knees bent, head slightly elevated, bed in lowest position
D. Bed in lowest position, wheels locked, place bed against wall
Answer: D. Bed in lowest position, wheels locked, place bed against wall
121. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the
formula
A. Every four to six hours
B. Continuously
C. In a bolus
D. Every hour
Answer: B. Continuously
122. The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The
nurse would caution the client to AVOID
A. Glycerine suppositories
B. Fiber supplements
C. Laxatives
D. Stool softeners
Answer: C. Laxatives
123. A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the
client’s comfort?
A. Increase oral fluid intake
B. Encourage visits from family and friends
C. Keep conversations short
D. Monitor vital signs frequently
Answer: C. Keep conversations short
124. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate
edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are
most appropriate?
A. Decreased carbohydrates and fat
B. Decreased sodium and potassium
C. Increased potassium and protein
D. Increased sodium and fluids
Answer: B. Decreased sodium and potassium
125. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal
impaction?
A. Presence of blood in stools
B. Oozing liquid stool
C. Continuous rumbling flatulence
D. Absence of bowel movements
Answer: B. Oozing liquid stool
126. A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned
home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The
client wants to know if visitors can come. The appropriate response from the home health nurse is that:
A. Visitors must wear a mask and a gown
B. There are no special requirements for visitors of clients on contact precautions
C. Visitors should wash their hands before and after touching the client
D. Visitors should wear gloves if they touch the client
Answer: C. Visitors should wash their hands before and after touching the client
127. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis.
Which admission orders should the nurse do first?
A. Institute seizure precautions
B. Monitor neurologic status every hour
C. Place in respiratory/secretion precautions
D. Cefotaxime IV 50 mg/kg/day divided q6h
Answer: C. Place in respiratory/secretion precautions
128. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for
falls?
A. Sensory perceptual alterations related to decreased vision
B. Alteration in mobility related to fatigue
C. Impaired gas exchange related to retained secretions
D. Altered patterns of urinary elimination related to nocturia
Answer: D. Altered patterns of urinary elimination related to nocturia
129. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a
priority in which situation?
A. An infant who has been identified to have botulism
B. A toddler who ate a number of ibuprofen tablets
C. A preschooler who swallowed powdered plant food
D. A school aged child who took a handful of vitamins
Answer: A. An infant who has been identified to have botulism
130. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the
staff members that the most significant routine infection control strategy, in addition to hand washing, to
be implemented is which of these?
A. Apply appropriate signs outside and inside the room
B. Apply a mask with a shield if there is a risk of fluid splash
C. Wear a gown to change soiled linens from incontinence
D. Have gloves on while handling bedpans with feces
Answer: D. Have gloves on while handling bedpans with feces
131. Which of these clients with associated lab reports is a priority for the nurse to report to the public
health department within the next 24 hours?
A. An infant with a positive culture of stool for Shigella
B. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
C. A young adult commercial pilot with a positive histopathological examination from an induced sputum
for Pneumocystis carinii
D. A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an
erythematous base that appear on the skin
Answer: B. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
132. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of
isolation is most appropriate for this client?
A. Reverse
B. Airborne
C. Standard precautions
D. Contact
Answer: D. Contact
133. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the
school. The information that would be most important to include would be which of these statements?
A. “The treatment requires reapplication in 8 to 10 days.”
B. “Bedding and clothing can be boiled or steamed.”
C. Children are not to share hats, scarves and combs.
D. Nit combs are necessary to comb out nits.
Answer: C. Children are not to share hats, scarves and combs.
134. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has
a headache and rate the pain 5 on a pain scale 0 to 10. The client’s blood pressure is currently 142/89.
Which interventions should the nurse implement? (Select all that apply)
A. Administer a daily dose of lisinopril as scheduled.
B. Assess the client for postural hypotension.
C. Notify the healthcare provider immediately
D. Provide a PRN dose of acetaminophen for headache
E. Withhold the next scheduled daily dose of warfarin
Answer: A. Administer a daily dose of lisinopril as scheduled.
D. Provide a PRN dose of acetaminophen for headache
135. An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic
cerebral vascular accident (CAV). Which interventions should the nurse include in the plan of care during
convalescence and rehabilitation? (Select all that apply.)
A. Measure neurological vital signs every 4 hours .
B. Place a bed side commode next to bed
C. Suction oral cavity every 4 hours.
D. Encourage family participate in the client's care
E. Play classical music in room while client is awake
Answer: A. Measure neurological vital signs every 4 hours .
136. A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why
the healthcare provider has prescribed all these medications. Which information should the nurse included
when responding to this client? (Select all that apply.)
A. One of the medications is used to anesthetize the corneal surface
B. Pupillary dilation is necessary to access the eye chamber for lens removal
C. The iris must be paralyzed during surgery to prevent it from reacting to light
D. A medication is used to induce sleep during the procedure
E. These medications assist in obstructing client´s vision during the surgery
Answer: A. One of the medications is used to anesthetize the corneal surface
B. Pupillary dilation is necessary to access the eye chamber for lens removal
C. The iris must be paralyzed during surgery to prevent it from reacting to light
137. The nurse is interacting with a female client who is diagnostic with postpartum depression. Which
findings should the nurse document as an objective signs of depression? (Select all that apply)
A. Expresses suicidal thoughts
B. Avoid eyes contact
C. Reports feeling sad
D. Has a disheveled appearance
E. Interacts with felt effect
Answer: B. Avoid eyes contact
138. A client who is hospitalized and recently diagnosed with Addison’s disease is now confused and
lethargic. Which actions should the nurse implement? (Select all that apply)
A. Measure capillary glucose level
B. Monitor cardiac telemetry pattern
C. Reduce rate of intravenous fluid infusion
D. Withhold next dose of corticosteroid
E. Initiate fall risk precautions
Answer: A. Measure capillary glucose level
B. Monitor cardiac telemetry pattern
E. Initiate fall risk precautions
139. 61-An older client is admitted for repair of a broken hip. To reduce the risk for infection in the
postoperative period, which nursing care interventions should the nurse include in the client’s plan of care?
(Select all that apply)
A. Teach client to use incentive spirometer q2 hours while awake
B. Remove urinary catheter as soon as possible and encourage voiding
C. Maintain sequential compression devices while in bed
D. Administer low molecular weight heparin as prescribed
E. Assess pain level and medicate PRN as prescribed
Answer: A. Teach client to use incentive spirometer q2 hours while awake
B. Remove urinary catheter as soon as possible and encourage voiding
140. An older adult client admitted to the stroke unit after recovery from the acute phrase of an ischemic
cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during
convalescence and rehabilitation? (Select all that apply.)
A. Measure neurological vital signs every 4 hours
B. Place a bedside commode next to the bed
C. Suction oral cavity every 4 hours
D. Encourage family to participate in the client’s care
E. Play classical music in room while client is awake
Answer: A. Measure neurological vital signs every 4 hours
D. Encourage family to participate in the client’s care
E. Play classical music in room while client is awake
141. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which
instructions should the nurse include in the client’s discharge plan? (Select all that apply).
A. Practice relaxation exercises
B. Limit fluids to avoid bladder distention
C. Space activities to allow for rest periods
D. Avoid persons with infections
E. Take warm baths before starting exercise
Answer: A. Practice relaxation exercises
C. Space activities to allow for rest periods
D. Avoid persons with infections
142. While assessing a client’s chest tube (CT), the nurse discovers bubbling in the water seal chamber of
the chest tube collection device. The client’s vital signs are: blood pressure of 80/40 mmHg, heart rate 120
beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the
nurse implement? (Select all that apply).
A. Provide supplemental oxygen
B. Auscultate bilateral lung field
C. Administer a nebulizer treatment
D. Reinforce occlusive CT dressing
E. Give PRN dose of pain medication
Answer: A. Provide supplemental oxygen
B. Auscultate bilateral lung field
D. Reinforce occlusive CT dressing
143. After an explosion at a factory one of the workers approaches the nurse and says “I am an unlicensed
assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign to this
worker who wants to help during the care of the wounded workers?
A. Get temperatures
B. Take blood pressure
C. Palpate pulses
D. Check alertness
Answer: C. Palpate pulses
144. Which of these clients would the nurse recommend to keep in the hospital during an internal disaster
at the agency?
A. An adolescent diagnosed with sepsis 7 days ago with vital signs maintained within low normal
B. A middle-aged woman documented to have had an uncomplicated myocardial infarction 4 days ago
C. An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis
D. A young adult in the second day of treatment for an overdose of acetometaphen
Answer: D. A young adult in the second day of treatment for an overdose of acetometaphen
145. The mother of a toddler who is being treated for pesticide poisoning asks: “Why is activated charcoal
used? What does it do?” What is the nurse's best response?
A. “Activated charcoal decreases the systemic absorption of the poison from the stomach.”
B. “The charcoal absorbs the poison and forms a compound that doesn't hurt your child.”
C. “This substance helps to get the poison out of the body by the gastrointestinal system.”
D. “The action may bind or inactivate the toxins or irritants that are ingested by children or adults.”
Answer: B. “The charcoal absorbs the poison and forms a compound that doesn't hurt your child.”
146. The nurse is to administer a new medication to a client. Which actions are in the best interest of the
client? Verify the order for the medication. Prior to giving the medication the nurse should say
A. “Please state your name?” Upon entering the room the nurse should ask:
B. “What is your name? What allergies do you have?” then check the client's name band and allergy band
As the room is entered say
C. “What is your name?” then check the client's name band Verify the client's allergies on the admission
sheet and order.
D. “Verify the client's name on the name plate outside the room then as the nurse enters the room ask the
client “What is your first, middle and last name?”
Answer: B. “What is your name? What allergies do you have?” then check the client's name band and
allergy band As the room is entered say
147. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for
a client with which medical condition?
A. Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV)
B. A positive purified protein derivative with an abnormal chest x-ray
C. A tentative diagnosis of viral pneumonia with productive brown sputum .
D. Advanced carcinoma of the lung with hemoptasis
Answer: B. A positive purified protein derivative with an abnormal chest x-ray
148. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family
wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to
prepare the body before the family enters the room? (Select all that apply)
A. Take out dentures and place in a labelled cup
B. Apply a body shroud
C. Place a small pillow under the head
D. Remove resuscitation equipment from the room
E. Gently close the eyes
Answer: C. Place a small pillow under the head
D. Remove resuscitation equipment from the room
E. Gently close the eyes
149. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce
hazards, the priority information for the nurse to include during the instructions to the client is which of
these statements?
A. In the initial 48 hours avoid contact with children and pregnant women, and after urination or
defecation flush the commode twice.
B. Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet
and flush it twice.
C. Your family can use the same bathroom that you use without any special precautions.
D. Drink plenty of water and empty your bladder often during the initial 3 days of therapy.
Answer: A. In the initial 48 hours avoid contact with children and pregnant women, and after urination or
defecation flush the commode twice.
150. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols
would be a priority for the nurse to implement?
A. Have the client cough into a tissue and dispose in a separate bag
B. Instruct the client to cover the mouth with a tissue when coughing
C. Reinforce for all to wash their hands before and after entering the room
D. Place client in a negative pressure private room and have all who enter the room use masks with shields
Answer: D. Place client in a negative pressure private room and have all who enter the room use masks
with shields
151. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the
PN?
A. Test a stool specimen for occult blood
B. Assist with the ambulation of a client with a chest tube
C. Irrigate and redress a leg wound
D. Admit a client from the emergency room
Answer: C. Irrigate and redress a leg wound
152. When assessing a client, it is important for the nurse to be informed about cultural issues related to
the client's background because
A. Normal patterns of behavior may be labelled as deviant, immoral, or insane
B. The meaning of the client's behavior can be derived from conventional wisdom
C. Personal values will guide the interaction between persons from 2 cultures
D. The nurse should rely on her knowledge of different developmental mental stages
Answer: A. Normal patterns of behavior may be labelled as deviant, immoral, or insane
153. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for
metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s
teaching plan? (Select all that apply.)
A. Take an additional dose for signs of hyperglycaemia
B. Recognize signs and symptoms of hypoglycaemia
C. Report persist polyuria to the healthcare provider
D. Use sliding scale insulin for finger stick glucose elevation
E. Take Glucophage with the morning and evening meal.
Answer: B. Recognize signs and symptoms of hypoglycaemia
C. Report persist polyuria to the healthcare provider
E. Take Glucophage with the morning and evening meal.
154. After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse,
“I have had it with that client. I just can’t do anything that pleases him. I’m not going in there again.” The
nurse should respond by saying
A. “He has a lot of problems. You need to have patience with him.”
B. “I will talk with him and try to figure out what to do.”
C. “He is scared and taking it out on you. Let's talk to figure out what to do.”
D. “Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the
day.”
Answer: C. “He is scared and taking it out on you. Let's talk to figure out what to do.”
155. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for
consideration for placement. The social worker telephoned the hospital unit for information about the
client’s mental status and adjustment. The appropriate response of the nurse should be which of these
statements?
A. I am sorry. Referral information can only be provided by the client’s health care providers.
B. “I can never give any information out by telephone. How do I know who you are?”
C. Since this is a referral, I can give you the this information.
D. I need to get the client’s written consent before I release any information to you.
Answer: D. I need to get the client’s written consent before I release any information to you.
156. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states
“I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain
their use and side effects.” The nurse should understand that
A. A referral is needed to the psychiatrist who is to provide the client with answers
B. The client has a right to know about the prescribed medications
C. Such education is an independent decision of the individual nurse whether or not to teach clients about
their medications
D. Clients with schizophrenia are at a higher risk of psychosocial complications when they know about
their medication side effects
Answer: B. The client has a right to know about the prescribed medications
157. A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client
with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the
medication? (Select all that apply)
A. Protect medication from exposure to light
B. Monitor for changes in level of consciousness
C. Observe for onset of generalized bruising or bleeding
D. Perform ongoing assessment of respiratory status
E. Administer slowly over at least two minutes
Answer: B. Monitor for changes in level of consciousness
158. A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which
interventions should the nurse implement? (Select all that apply)
A. Give the client 4 ounces of orange juice
B. Obtain blood pressure and pulse rate
C. Provide the client with ½ cup diet carbonated soda
D. Administer a PRN dose of regular insulin
E. Check the client’s current finger stick blood glucose
Answer: E. Check the client’s current finger stick blood glucose
159. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which
finding should the nurse document as an objective sign of depression? (Select all that apply)
A. Interacts with a flat affect
B. Avoids eye contact
C. Has a dishevelled appearance
D. Report feeling sad
E. Expresses suicidal thoughts
Answer: A. Interacts with a flat affect
B. Avoids eye contact
C. Has a dishevelled appearance
160. A client who is hospitalized and recently is now confused and lethargic. Which actions should the
nurse implement? (Select all that apply)
A. Measure capillary glucose level
B. Monitor cardiac telemetry pattern
C. Reduce rate of intravenous fluid infusion
D. Withhold next dose of corticosteroid
E. Initiate fall risk precautions
Answer: A. Measure capillary glucose level
B. Monitor cardiac telemetry pattern
E. Initiate fall risk precautions
