2020-2021 HESI Chamberlain University Medical Surgical Version 1 With Answers-541 Solved Questions

HESI MED SURG VERSION 1 2020/2021 Questions & Answers
Nursing (Chamberlain University)
HESI MED SURG VERSION 1 2020/2021 Questions & Answers
1. What instruction should the nurse include in the discharge teaching plan of a client who
had a cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avoid heavy lifting
c. Use a metal eye shield on operative eye during the day
d. Administer eye ointment before applying eye drops
Answer: b. Light housekeeping is permitted but avoid heavy lifting
2. A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He
is short of breath, febrile, and coughing green colored sputum. Which intervention should the
nurse implement first?
a. Obtain a sputum sample for culture
b. Check his oxygen saturation level
c. Administer an oral antipyretic
d. Auscultate bilateral lung sound
Answer: a. Obtain a sputum sample for culture
3. An elder male client tells the nurse that he is loosing sleep because he has to get up several
times at night to go to the bathroom that he has trouble starting his urinary stream and that he
does not feel like his bladder is ever completely empty. Which intervention should the nurse
implement?
a. collect a urine specimen for culture analysis
b. obtain a fingerstick blood glucose level
c. palpate the bladder above the symphysis pubis
d. review the client fluid intake
Answer: c. palpate the bladder above the symphysis pubis

4. An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection
(UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum
laboratory value warrants the most immediate intervention by the nurse?
a. blood ph of 7.30
b. glucose of 350 mg /dl
c. white blood cell count of 15000mm
d. potassium of 2.5 meq/l
Answer: d. potassium of 2.5 meq/l
5. A client with sickle cell anemia develops a fever during the last hour of administration of a
unit of packed red blood cell. When notifying the healthcare provider what information
should the nurse provide first using the SBAR communication process?
a. explain specific reason for urgent notification
b. preface the report by stating the clients name and admitting diagnosis
c. communicate the pre-transfusion temperatures
d. optain prn prescription for acetaminophen for fever 101f
Answer: a. explain specific reason for urgent notification
6. An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to
aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this
client for discharge what important aspect regarding his medication therapy should the nurse
explain?
a. AZT therapy must be stopped when IV aerosol pentamine is being used.
b. IV pentamine will be given until oral pentamine can be tolerated
c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month
d. Iv pentamine may offer protection to others aids related conditions such as kaposis
sarcoma
Answer: c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine
every month
7. A client subjective data includes dysuria, urgency, and urinary frequency. What action
should the nurse implement next?
a. collect a clean catch specimen
b. palpate the suprapubic region

c. instruct to wipe from front to back
d. inquire about recent sexual activity
Answer: a. collect a clean catch specimen
8. A client tells the nurse that her biopsy results indicate that the cancer cells are well
differentiated How should the nurse respond?
a. offer the client reassurance that this information indicates that the clients cancer cells are
benign
b. explain that these tissue cells often respond more effectively to radiation than to
chemotherapy
c. ask the client in the healthcare provider has giving her any information about the
classification of her cancer
d. help the client make plans to begin inmediate treatment since her cancer is likely to spread
quickly
Answer: c. ask the client in the healthcare provider has giving her any information about the
classification of her cancer
9. A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment
clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first?
a. monitor bp q45 minutes
b. lower the head of the chair and elevate feet
c. stop dialysis treatment
d. administer 5%albumin IV
Answer: c. ask the client in the healthcare provider has giving her any information about the
classification of her cancer
10. A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin
sodium 25, 000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage
should be increase 900 units/hr. The nurse should program the infusion pump to deliver how
many ml/hr?
a. 8
b. 9
c. 10
d. 12

Answer: b. 9
11. The nurse is obtaining the admission history for a client with suspected peptic ulcer
disease (PUD). Which subjective data reported by the client supports this diagnosis?
a. upper mid abdominal gnawing and burning pain
b. severe abdominal cramps and diarrhea after eating spicy foods
c. marked loss of weight and appetite over the last few months
d. use of chewable and liquid antacids for indigestion
Answer: a. upper mid abdominal gnawing and burning pain
12. The nurse is providing preoperative education for a jewish client schedule to receive a
xenograft graft to promote burn healing. Which information should the nurse provide this
client?
a. the xenograft is taken from nonhuman sources
b. grafting increases the risk for bacterial infection
c. as the burn heals the graft permanently attaches
d. grafts are later removed by debriding procedure
Answer: a. upper mid abdominal gnawing and burning pain
13. A client who took a camping vacation two weeks ago in a country with a tropical climate
comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding
is most important for the nurse to report?
a. jaundice sclera
b. intestinal cramping
c. weakness and fatigue
d. weight loss
Answer: a. jaundice sclera
14. During a home visit the nurse assesses the skin of a client with eczema who reports than
an exacerbation of symptoms has occurred during the last week. Which information is most
useful in determining the possible cause of the symptoms?
a. an old friend with eczema came for visit
b. recently received an influenza immunization
c. corticosteroid cream was applied to eczema

d. a grandson and his new dog recently visited
Answer: d. a grandson and his new dog recently visited
15. When explaining dietary guidelines to a client with acute glomerulonephritis (AGN)
which instruction should the nurse include in the dietary teaching?
a. select a protein rich food daily
b. restrict sodium intake
c. eat high potassium foods
d. Avoid foods high in carbohydrate
Answer: b. restrict sodium intake
16. A male client who is 24hr post operative for an exploratory laparoctomy complains that
he is starving because he has had no real food since before surgery. Prior to advancing his
diet which intervention should the nurse implememt?
a. discontinue intravenous therapy
b. Assess for abdominal distension and tenderness
c. Obtain a prescription for a diet change
d. Auscultate bowel sound in all four quadrants
Answer: d. Auscultate bowel sound in all four quadrants
17. A client diagnose with stable angina secondary to ischemic heart disease has a
prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to
follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart?
a. drive to the nearest emergency department
b. take another NTG SL tablet and lie down until angina subsides
c. call primary healthcare provider
d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg
Answer: d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg
18. After taking orlistat (Xenical) for one week a femela client tells the home health nurse
that she is experiencing increasingly frequent oily stools and flatus. What action should the
nurse take?
a. obtain stool specimen to evaluate for occult blood and fat content
b. instruct the client to increase her intake of saturated fats over the next week

c. ask the client to describe her dietary intake history for the last several days
d. advice the client to stop taking the drug and contact the healthcare provider
Answer: c. ask the client to describe her dietary intake history for the last several days
19. Two days after an abscess of the chin was drained the client returns to the clinic with
fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and
cleansed the wound today with provide iodine (Betadine) solution. Which intervention should
the nurse implement first?
a. determine if the client has a history of diabetes
b. assess airway patency and oxygen saturation
c. review recent medication history and allergies
d. obtain samples for complete blood count and cultures
Answer: b. assess airway patency and oxygen saturation
20. A client experiences an ABO incompatibility reaction after multiple blood transfusions.
Which finding should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
Answer: a. low back pain and hypotension
21. A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the
intensive care unit with hyperglycemic nonketotic syndrome (HHNS). A sliding scale
protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a
continuous blood glucose monitoring device that is attached to the client’s central venous
catheter. When the client’s respirations become labored and his lungs sound indicate crackles
what action should the nurse take?
a. collect a specimen for a white blood cell count and cultures
b. determine the clients glycosylated hemoglobin (A1C)
c. administer insulin IV push until the clients fluid volume is adjusted
d. decrease infusion rate to address fluid overload
Answer: d. decrease infusion rate to address fluid overload

22. When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the
previously applied patch is intact on the client’s upper back and the client denies pain. What
action should the nurse take?
a. Remove the patch and consult with the healthcare provider about the client pain resolution
b. Place the patch on the clients shoulder and leave both patches in place for 12 hours
c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch
d. Apply a new patch in a different location after removing the original patch
Answer: d. Apply a new patch in a different location after removing the original patch
23. A client who had a myocardial infarction is admitted to the coronary critical care unit
(CCU) with a nitro glycerin drip infusing. The clients last blood pressure measurements was
78/36.What action should the nurse implement?
a. obtain blood pressure q5 minutes using duranap machine
b. change the dilution of the nitro glycerin infusion
c. reduce the rate of the nitro glycerin infusion
d. begin dopamine infusion at 5mcg/kg per minute
Answer: c. reduce the rate of the nitro glycerin infusion
24. An adolescent is admitted to the hospital because of a suicide attempt with an overdose of
acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor
during the first 72 hours following ingestion of this overdose?
a. BUN creatinine specific gravity
b. White blood count, hemoglobin hematocrit
c. PH, PCO2, HCO3
d. LDH OR LD, SGOT OR ALT, SGPT OR AST
Answer: d. LDH OR LD, SGOT OR ALT, SGPT OR AST
25. An elderly post-operative female client is receiving morphine sulfate via a PCA pump.
Which assessment finding should prompt a nurse to administer the prescribed PRN
medication naloxone?
a. her respiratory rate is 7 breath/minute
b. she indicates that she feels as if she cannot get enough air to breath
c. she has intercostal retractions and bilateral wheezing is auscultated
d. her pulse oximeter is 89% on room air

Answer: a. her respiratory rate is 7 breath/minute
26. Which assessment finding indicates to the nurse that the muscarinic agent bethanechol
(Urecholine) is effective for a client diagnose with urinary retention?
a. urinary output equal to intake
b. no terminal urinary dribbling
c. denies stress incontinence
d. absence of xerostomia
Answer: a. urinary output equal to intake
27. Following involvement in a motor vehicle collision, a middle aged adult client is admitted
to the hospital with multiple facial fractures. The client’s blood alcohol level is high on
admission. Which PRN prescription should be administer if the clients begins to exhibit signs
and symptoms of delirium tremens (DT s)?
a. Lorazepam (Ativan) 2mg IM
b. Chlorpromazine (thorazine) 50 mg IM
c. Prochlorperazine (Compazine) 5 mg IM
d. Hydromorphone (Dilaudid) 2 mg IM
Answer: a. Lorazepam (Ativan) 2mg IM
28. Which instructions should the nurse include in the teaching plan of a client who is taking
the diuretic spironolactone (Aldactone)?
a. call the healthcare provider f you develop gynecomastia
b. Take the medication in the morning
c. Avoid caffeine and smoking
d. Increase your consumption of bananas and oranges
Answer: b. Take the medication in the morning
29. A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When
should the nurse instruct the client to take the glucagon?
a. after meals to increase endogenous insulin secretion
b. after insulin administration to prevent hypoglycemia
c. when recognized signs of severe hypoglycemia occur
d. when unable to eat during sick days

Answer: c. when recognized signs of severe hypoglycemia occur
30. A client with hyperthyroidism is being treated with radioactive iodine (I- 131). Which
explanation should be included in preparing this client for this treatment?
a. describe radioactive iodine as a tasteless, colorless medication administered by the
healthcare provider
b. explain the need for using lead shields for 2 to 3 weeks after the treatment
c. describe the signs of goiter because this is a common side effects of radioactive iodine
d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately
Answer: a. describe radioactive iodine as a tasteless, colorless medication administered by
the healthcare provider
31. A female client is being treated for tuberculosis with rifampin (rifadin) which statement
indicates that further teaching is needed?
a. "I will take my usual contraceptive for birth control."
b. "I should avoid drinking alcohol while taking this medication."
c. "I need to monitor my urine and sweat for any changes in color."
d. "I will complete the full course of treatment, even if I start feeling better."
Answer: a. "I will take my usual contraceptive for birth control."
32. A client is discharged with a prescription for warfarin (Coumadin). What discharge
instructions should the nurse emphasize to the client?
a. take a multi vitamin supplement daily
b. use an astringent for superficial bleeding
c. avoid going barefoot especially outside
d. include large amounts of spinach in the diet
Answer: c. avoid going barefoot especially outside
33. In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone
intranasal which serum lab test is most important for the nurse to monitor?
a. osmolality
b. calcium
c. platelets
d. glucose

Answer: a. osmolality
34. After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a
severe migraine headache the nurse should explain that relief can be expected within what
time frame?
a. 2 hours
b. 5 minutes
c. 1 hour
d. 15 minutes
Answer: d. 15 minutes
35. A client with hypertension who has been taking labetalol for two weeks, reports a five
pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to
obtain?
a. capillary refill
b. body temperature
c. muscle strength
d. breath sounds
Answer: d. breath sounds
36. A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops
for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What
explanation should the nurse provide?
a. The eye drops slow pupil response to accommodate for darkness
b. The drops increase the fluid in the eyes and cloud the visual field ( possible answer)
c. The drug can cause lens to become more opaque
d. The medication causes pupils to dilate which reduces night vision
Answer: a. The eye drops slow pupil response to accommodate for darkness
37. A client who is taking and oral dose of tetracycline complains of gastrointestinal upset.
What snack should the nurse instruct the client to take with the tetracycline?
a. toasted wheat bread and jelly
b. cheese and crackers
c. cold cereal with skim milk

d. fruit flavored yogurt
Answer: a. toasted wheat bread and jelly
38. The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which
physiologic action?
a. Facilitates transport of glucose into the cell
b. Increases intracellular receptor site sensitivity
c. Stimulates function of beta cells in the pancreas
d. Delays carbohydrates digestion and absorption
Answer: a. Facilitates transport of glucose into the cell
39. The health care provider prescribe a medication for an older adult client who is
complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should
question which prescription?
a. Eszoplicone (Lunesta)10 mg orally at bed time
b. Zolpidem 10 mg orally at bed time
c. Temazepan orally at bed time
d. Ramelteon orally at bedtime
Answer: a. Eszoplicone (Lunesta)10 mg orally at bed time
40. A male client reports to the nurse that he is experiencing GI distress from high dose of a
corticosteroid and is planning to stop taking the medication. In response to the client’s
statement what nursing action is most important for the nurse to take?
a. Encourage the client to take medication with food to decrease GI distress
b. Advice the client that the medication should be stopped gradually rather than abruptly.
c. Review the clients dosing schedule to ensure he is taking the prescribed amount
d. Assess the client for other indication of adverse effects of corticosteroid
Answer: b. Advice the client that the medication should be stopped gradually rather than
abruptly.
41. Fifteen minutes after receiving sulfa athenozole. A male client report a burning sensation
over his abdomen chest and groin. Which intervention is most important for the nurse to
implement?
a. Auscultate lung sounds for wheezing

b. Review the clients list if drugs allergies
c. Add sulfamethinozole to clients allergies
d. Check neurological vital signs
Answer: b. Review the clients list if drugs allergies
42. Antibiotic resistant organism are a major infection control problems. To help minimize
the emergence of resistant bacteria what instruction should the nurse provide to the clients?
a. stop taking prescribed antibiotics when symptoms decrease
b. avoid using antibiotics when suffering from colds or the flu
c. ask the healthcare provider to prescribe the newest antibiotic when needed
d. request a prescription for first time vancomysin for a sore throat
Answer: b. avoid using antibiotics when suffering from colds or the flu
43. A client with symptoms of influenza that started the previous day ask the clinic nurse
about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse
provide?
a. Advise the client once symptoms occur is too late to receive an influenza vaccination
b. Refer the client to the healthcare provider at the clinic to obtain a medication prescription
c. Explain to the client that antibiotics are not useful in treating viral infections such as
influenza
d. Instruct the client that over the counter medications are sufficient to manage influenza
symptoms
Answer: b. Refer the client to the healthcare provider at the clinic to obtain a medication
prescription
44. Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2
grams using an infusion pump to deliver the dose in one hour, the client reports feeling
nauseated. What action should the nurse implement?
a. stop medication infusion and notify the healthcare provider of the adverse effect
b. increase the rate of the infusion to complete the dose of the medication more rapidly
c. continue the infusion and administer a prn antiemetic prescription
d. reassure the client that the nausea is not related to the iv infusion
Answer: c. continue the infusion and administer a prn antiemetic prescription

45. The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimer’s
disease as an intervention for which client problem?
a. fluid volume excess
b. disturbed thought processes
c. chronic pain
d. altered breathing patterns
Answer: b. disturbed thought processes
46. To prevent deep vein thrombosis following knee replacement surgery, an adult male client
is receiving enoxaparin (Lovenox) subcutaneously daily.
Which laboratory finding requires immediate action by the nurse?
a. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI)
b. Hematocrit 45%
c. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI)
d. Platelet count of 100, 000/mm3 or 100x109/ L (SI)
Answer: d. Platelet count of 100, 000/mm3 or 100x109/ L (SI)
47. A client with type 2 diabetes mellitus is managed with metformin (Glucophage), an oral
hypoglycemic agent. The primary health care provider prescribes ad additional medication
injected exenatide (byetta). Which information is most important for the nurse to teach this
client?
a. Administer subcutaneously after meals
b. Consume additional sources of potassium
c. Notify the healthcare provider if anorexia occurs
d. Watch for signs of jitteriness or diaphoresis
Answer: a. Administer subcutaneously after meals
48. A client is who is diagnose with schizophrenia receives a prescription for an atypical
antipsychotic drug aripipazole (Abilify). Which assessment should the nurse perform to
monitor for an adrenergic receptor antagonist side effect that commonly occurs atypical
antipsychotic agents?
a. observe the client hallucinatory behaviors
b. obtain the client finger stick glucose levels
c. measure the clients lying and standing blood pressure

d. determine the clients abnormal involuntary movements scale (AIMS)
Answer: b. obtain the client finger stick glucose levels
49. A client with pheocromocytoma reports the onset of a severe headache. The nurse
observes that the client is very diaphoretic. Which assessment data should the nurse obtain
first?
a. Blood pressure
b. Oxygen saturation
c. Heart rate
d. Temperature
Answer: a. Blood pressure
50. The drainage in the chest tube of a client with emphysema has changed from clear watery
fluid. What action would be best for the nurse to take/
a. Maintain the current IV antibiotic schedule
b. Notify the healthcare provider
c. Increase the IV fluids to prevent dehydration
d. Administer pain medication to reduce discomfort
Answer: b. Notify the healthcare provider
51. A client is admitted with a sudden onset of right sided the nurse complete first?
a. Observe for peripheral edema
b. Administer diuretics as prescribed
c. Obtain a chest x-ray
d. Assess lung sounds for crackles
Answer: a. Observe for peripheral edema
52. When planning care for a client newly diagnose with open angle glaucoma, the nurse
identifies a priority nursing diagnosis of “ Visual sensory/perceptual alterations”. This
diagnosis is based on which etiology?
a. Decreased peripheral vision
b. Increased intraocular pressure
c. Narrowing of the anterior chamber
d. Blurred central vision

Answer: a. Decreased peripheral vision
53. A client in the operating room received succinylcholine. The client is experiencing muscle
rigidity and has an extremely high temperature. What action should the nurse implement?
a. Call the PACU nurse to prepare for prolonged ventilatory support
b. Administer dantrolene sodium to treat malignant hyperthermia
c. Increase the room temperature to warm the client
d. Administer a bolus of normal saline to correct dehydration
Answer: b. Administer dantrolene sodium to treat malignant hyperthermia
54. A client who is receiving packed red blood cells develops nausea and vomiting. What
action should the nurse take first?
a. Stop the infusion of blood
b. Notify the healthcare provider immediately
c. Administer an antiemetic
d. Increase the infusion rate of normal saline
Answer: a. Stop the infusion of blood
55. A client with type 2 diabetes mellitus is admitted to the hospital for uncontrolled DM.
Insulin therapy is initiated with initial dose of Humulin insulin at 8:00 at 16:00 the client
complains of diaphoresis, rapid heart beat, and feeling shaky. What should the nurse do first?
a. Administer a dose of glucagon
b. Determine the client's current glucose level
c. Increase the infusion rate of intravenous fluids
d. Notify the healthcare provider
Answer: b. Determine the client's current glucose level
56. After suctioning the patient with an endotracheal tube, which assessment finding indicates
to the nurse that the intervention was effective?
a. Increase in breath sounds
b. Decrease in respiratory rate
c. Improvement in oxygen saturation
d. Decrease in the amount of secretions
Answer: c. Improvement in oxygen saturation

57. The nurse observes an increase number of blood clots in the drainage tubing of a client
with continuous bladder irrigation following a transurethral resection of the prostate (TURP).
What is the best initial nursing action?
a. Provide additional oral fluid intake
b. Increase the flow rate of the irrigation solution
c. Assess for signs of hypovolemia
d. Notify the healthcare provider immediately
Answer: b. Increase the flow rate of the irrigation solution
58. Which nursing diagnosis should be selected for a client who is receiving thrombolytic
infusions for treatment of an acute myocardial infarction?
a. Risk for injury related to effects of thrombolysis
b. Acute pain related to myocardial ischemia
c. Decreased cardiac output related to myocardial infarction
d. Ineffective tissue perfusion related to blood clot formation
Answer: a. Risk for injury related to effects of thrombolysis
59. The nurse is assessing a client who has returned from surgery following a thoracotomy.
Which finding indicates the client is experiencing adequate gas exchange?
a. The client demonstrates effective coughing and deep breathing exercises
b. The client’s oxygen saturation is 90%
c. The client has clear, symmetrical breath sounds
d. The client reports no pain or discomfort
Answer: c. The client has clear, symmetrical breath sounds
60. When caring for a client with nephrotic syndrome which assessment is most important for
the nurse to obtain?
a. Blood pressure
b. Daily weight
c. Urine output
d. Oxygen saturation
Answer: b. Daily weight

61. A client who had a biliopancreatic diversion procedure (BOP) 3 months ago is admitted
with severe dehydration. Which assessment finding warrants immediate intervention by the
nurse?
a. Increased thirst
b. Gastroccult positive emesis
c. Dry mucous membranes
d. Decreased urine output
Answer: b. Gastroccult positive emesis
62. A female client with possible acute renal failure (ARF) is admitted to the hospital and
mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out this prescription,
what intervention should the nurse implement?
a. No specific nursing action is required
b. Instruct the client to empty the bladder
c. Collect a clean catch urine specimen
d. Obtain vital signs and breath sounds
Answer: d. Obtain vital signs and breath sounds
63. The nurse positions a male client for a lumbar puncture by placing him in the side-lying
position with his knees flexed and pulled toward his trunk. What action should the nurse
implement next?
a. Call another nurse to assist the healthcare provider
b. Provide a small pillow for the client to curl around
c. Instruct the client to perform a Valsalva maneuver
d. Support the client’s head bent forward to the chest
Answer: d. Support the client’s head bent forward to the chest
64. When teaching a client with osteoporosis to increase weight-bearing exercise, how should
the nurse explain the purpose of this activity?
a. Strengthen leg muscles
b. Promote venous return
c. Increase bone strength
d. Restore range of motion
Answer: c. Increase bone strength

65. A male tells the clinic nurse that he is experiencing burning on urination, and assessment
that he had sexual intercourse four days ago with a woman he casually met. Which action
should the nurse implement?
a. Observe the perineal area for a chancroid-like lesion
b. Obtain a specimen of urethral drainage for culture
c. Identify all sexual partners in the last four days
d. Assess for perineal itching, erythema, and excoriation
Answer: b. Obtain a specimen of urethral drainage for culture
66. An older female client with long term type 2 diabetes mellitus (DM) is seen in the doctor
routine health assessment. To determine if the client is experiencing any long-term
complications of DM, which assessments should the nurse obtain? Select all that apply:
a. Visual acuity
b. Serum creatinine and blood urea nitrogen (BUN)
c. Signs of respiratory tract infection
d. Sensation in feet and legs
e. Skin condition of lower extremities
Answer: a. Visual acuity
b. Serum creatinine and blood urea nitrogen (BUN)
d. Sensation in feet and legs
e. Skin condition of lower extremities
67. Which laboratory test result is most important for the nurse to report to the surgeon prior
to a client’s scheduled abdominal surgery?
a. Potassium level of 4 mEq/liter
b. Blood glucose of 90 mg/dl
c. Serum creatinine of 5 mg/dl
d. Hemoglobin level of 13 grams
Answer: c. Serum creatinine of 5 mg/dl
68. A client who has a history of long-standing back pain treated with methadone
(Dolophine), is admitted to the surgical unit following urological surgery. What modifications

in the plan of care should the nurse make for this client’s pain management during the
postoperative period?
a. Use minimal parenteral opioids for surgical pain, in addition to oral methadone
b. Maintain client’s methadone, and medicate surgical pain based on pain rating
c. Consult with surgeon about increasing methadone in lieu of parenteral opioids
d. Make no changes in standard pain management for this surgery and hold methadone
Answer: b. Maintain client’s methadone, and medicate surgical pain based on pain rating
69. The nurse applies an automatic external defibrillator (AED) to a client who collapsed in
an exam room at a community clinic. What action should the nurse take next?
a. Determine the defibrillator reading
b. Assess the client’s oxygen saturation
c. Bring a crash cart to the exam room
d. Measure the client’s blood pressure
Answer: a. Determine the defibrillator reading
70. Which change in lab values would indicate to the nurse that treatment for gout is
successful?
a. Decreased serum uric acid
b. Decreased serum purine
c. Increased serum uric acid
d. Increased serum purine
Answer: a. Decreased serum uric acid
71. The nurse reports that a client is at risk for a brain attack (stroke) finding?
a. Jugular vein distention
b. Palpable cervical lymph node
c. Carotid bruit
d. Nuchal rigidity
Answer: c. Carotid bruit
72. The nurse is assessing a group of older adults. What factor in a male client’s history puts
him at greatest risk for developing colon cancer?
a. Is excessively exposed to sunlight

b. Eats a high-fat diet
c. Smokes cigars
d. Has intestinal polyps
Answer: d. Has intestinal polyps
73. While taking routine vital signs at 0400 AM, the nurse notes that a client who had a total
knee replacement the previous day has a heart rate of 126 beats/minute. What action should
the nurse take first?
a. Compare heart rate trends with blood pressure trends
b. Review the medical record for a history of cardiac disease
c. Check surgical drainage system and bandage for bleeding
d. Determine current pain level using a 10-point scale
Answer: c. Check surgical drainage system and bandage for bleeding
74. A client who suffered an electrical injury on the left foot is admitted to the burn include in
this client’s plan of care? (incomplete)
a. Assess lung sounds q4 hours
b. Perform passive range of motion
c. Evaluate level of consciousness
d. Continuous cardiac monitoring
Answer: d. Continuous cardiac monitoring
75. The nurse is taking a client’s blood pressure sphygmomanometer cuff is inflated. What
(incomplete)
a. Administer a prescribed PRN antianxiety
b. Assess the client’s recent serum calcium
c. Notify the healthcare provider of the situation
d. Prepare to implement seizure precautions
Answer: d. Prepare to implement seizure precautions
76. A client with eczema is using an over-the-counter (OTC) topical product with urea 10%
OTC (Aqua Care Cream) to the affected skin areas. Which finding reflects the expected
therapeutic response?
a. Decreased weeping of ulcerations in the affected area

b. Healing with a return to normal skin appearance
c. Reduced pain in eczematous areas
d. Hydration of affected dry skin areas
Answer: d. Hydration of affected dry skin areas
77. During an annual health check, the clinic nurse updates an adult female’s health history.
When discussing the woman’s history of lactose intolerance, the client reports that it has been
years since she last consumed dairy products. What dietary suggestions should the nurse
recommend to help ensure that the client receives an adequate intake of calcium? Select all
that apply:
a. Increase intake of salmon, sardines, tofu, and leafy green vegetables
b. Sip a half-cup of milk during a mid-day meal at least every other day
c. Eat at least six servings of citrus fruits weekly
d. Include 2 to 3 servings of yellow and green squash weekly
e. Take a calcium supplement with vitamin D daily
Answer: a. Increase intake of salmon, sardines, tofu, and leafy green vegetables
e. Take a calcium supplement with vitamin D daily
78. A healthcare worker with no known exposure to tuberculosis has received a Mantoux
tuberculosis skin test. The nurse’s assessment of the test after 72 hours indicates 5mm of
erythema without induration. What is the best initial nursing action?
a. Review client’s history for possible exposure to TB
b. Instruct the client to return for a repeat test in 1 week
c. Refer client to a healthcare provider for isoniazid (INH) therapy
d. Document negative results in the client’s medical record
Answer: d. Document negative results in the client’s medical record
79. A male client in skeletal traction tells the nurse that he is frustrated because he needs help
repositioning himself in bed. Which intervention should the nurse implement?
a. Inform the client that it is the nurse’s responsibility to reposition
b. Provide an overhead trapeze to the bed for the client to use
c. Place a draw sheet under the client to assist with repositioning
d. Administer an intravenous PRN anti-anxiety medication
Answer: b. Provide an overhead trapeze to the bed for the client to use

80. In planning care for a client with pneumonia, which nursing problem should the nurse
identify as the priority?
a. Impaired gas exchange related to the effects of alveolar-capillary membrane changes
b. Acute pain related to the effects of inflammation of the parietal pleura
c. Deficient fluid volume related to fever, infection, and increased metabolic rate
d. Disturbed sleep pattern related to pain, dyspnea, and hospitalization
Answer: a. Impaired gas exchange related to the effects of alveolar-capillary membrane
changes
81. A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain.
What is the best initial nursing action?
a. Encourage frequent mouth care
b. Administer a topical analgesic per PRN protocol
c. Cleanse the tongue and mouth with glycerin swabs
d. Obtain a soft diet for the client
Answer: a. Encourage frequent mouth care
82. A client returns from surgery following a hiatal hernia repair via Nissen fundoplication.
Which position should the nurse implement for this client?
a. Right side-lying to promote stomach emptying
b. Prone to apply external pressure to the suture line
c. Left side-lying to reduce stress on the suture line
d. 30-degree semi-Fowler’s to drop the diaphragm
Answer: d. 30-degree semi-Fowler’s to drop the diaphragm
83. An adult woman with Grave’s disease is admitted with severe dehydration is currently
restless and refusing to eat. Which action is most important for the nurse to implement?
a. Keep room temperature cool
b. Determine the client’s food preferences
c. Maintain a patent intravenous site
d. Teach the client relaxation techniques
Answer: c. Maintain a patent intravenous site

84. The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit.
Which intervention has the highest priority in providing care for this client?
a. Administer initial dose of broad-spectrum antibiotic
b. Instruct the client to force fluids hourly
c. Obtain results of culture and sensitivity of CSF
d. Assess the client for symptoms of hyponatremia
Answer: a. Administer initial dose of broad-spectrum antibiotic
85. A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritis
caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema
with purulent exudate at the site. What action should the nurse implement?
a. Schedule an appointment for the client to see the healthcare provider
b. Advise the client to apply plastic wrap over the ointment to promote healing
c. Explain that the client needs to complete all prescribed doses of the medication
d. Instruct the client to continue the ointment until all erythema is relieved
Answer: a. Schedule an appointment for the client to see the healthcare provider
86. During a paracentesis, two liters of fluid are removed from the abdomen of a client with
ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the
first hour. What action should the nurse implement?
a. Palpate for abdominal distention
b. Clamp drainage tube for 5 minutes
c. Continue to monitor the fluid output
d. Send fluid to the lab for analysis
Answer: d. Send fluid to the lab for analysis
87. The nurse assesses the dressing of a client who has just returned from post anesthesia and
finds that the dressing is wet with a moderate amount of bright red bloody drainage. What
action should the nurse take?
a. Replace dressing with a new sterile dressing, and monitor the wound hourly until bleeding
is stopped
b. Call surgery and request that the surgeon see the wound prior to leaving the hospital
c. Reinforce the dressing and document that a moderate amount of sanguineous drainage was
on the dressing

d. Document that the dressing was saturated with serous drainage, and do not change the
dressing
Answer: a. Replace dressing with a new sterile dressing, and monitor the wound hourly until
bleeding is stopped
88. While the home health nurse is making a home visit, a client with a history of seizures
demonstrates tonic-clonic seizure activity. What action should the nurse implement first?
a. Direct a family member to call emergency services
b. Ascertain the trigger event
c. Protect the client’s head with a pillow
d. Observe the postictal breathing pattern
Answer: c. Protect the client’s head with a pillow
89. A client who weighs 176 pounds is admitted to the intensive care unit with a serum
glucose level of 600 mg/dl and a serum acetone level of 50 mg/dl. Regular insulin at a rate of
0.1unit/kg/hour is prescribed. The pharmacy provides a solution of Regular insulin 100
units/100 ml of normal saline. The nurse should set the infusion pump to deliver how many
ml/hour? (Enter numeric value only)
a. 8ML/H
b. 9ML/H
c. 5ML/H
d. 12ML/H
Answer: a. 8ML/H
90. A client whose history includes IV drug abuse is admitted to the intensive care unit (ICU)
with Kaposi’s sarcoma associated with Acquired Immune Deficiency Syndrome (AIDS).
Which intervention is most important for the nurse to include in the client’s plan of care?
a. Observe for adverse medication reactions
b. Assess for signs of AIDS dementia
c. Identify signs of opportunistic infections
d. Locate local HIV support groups
Answer: c. Identify signs of opportunistic infections

91. (Photo) The charge nurse observes a newly employed nurse gathering equipment to
obtain a venous blood sample from a client’s implanted port. The nurse has obtained the
equipment seen in the photo. What actions should the charge nurse take? (Select all that
apply)
a. Guide the nurse in inserting the needle at a 45 degree angle
b. Remind the nurse to wear sterile gloves for this procedure
c. Instruct the nurse to obtain several red-topped tubes
d. Determine if the nurse has ever performed this skill
e. Assist in obtaining the correct needle to access the port
Answer: a. Guide the nurse in inserting the needle at a 45 degree angle
b. Remind the nurse to wear sterile gloves for this procedure
d. Determine if the nurse has ever performed this skill
e. Assist in obtaining the correct needle to access the port
92. After a computer tomography (CT) scan with intravenous contrast medium, a client
returns to the room complaining of shortness of breath and itching. Which intervention
should the nurse implement?
a. Send another nurse for an emergency tracheotomy set
b. Call respiratory therapy to give a breathing treatment
c. Review the client's complete list of allergies
d. Prepare a dose of Epinephrine (Adrenalin)
Answer: c. Review the client's complete list of allergies
93. The nurse is reviewing blood pressure readings for a group of client's on a medical unit.
Which client is at the highest risk for complications related to hypertension?
a. Young adult Hispanic female who has a hemoglobin of 11 gm and drinks beer every day
b. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL
c. Older Asian male who eats a diet consisiting of smoked, cured, and pickled foods.
d. Post-menopausal Caucasian female who overeats and is 20% above ideal body weight
Answer: b. Middle-aged African-American male who has a serum creatinine level of 2.9
mg/dL
94. Shingles
Answer: Teach the pt about phantom pain

95. Shingles Select all the apply
Answer: • pain
• ability
• skin integrity
96. Patient with ezcema applying cream to is working:
Answer: Healing with a Return Skin to Normal Appearance.
97. Pt with obesity high glucose level is at risk for?
Answer: Cardiovascular Disease
98. For anemia what doesn’t have iron, which foods are not rich in iron?
Answer: No Orange
99. Pt. W/ risk of dvt
Answer: Perform Rom Exercises also legs exercise can be other way to answer
100. Discharge for venous ulcers select all apply?
Answer: • elevate the feet when laying down
• check brownish skin around the ankles
• vitamins
101. Pt. with siadh:
Answer: Hard Candy For Thirst.
102. Pt Arrive To Pacu Postop Moaning What To Do:
Answer: Check Pulse, BP And Respirations.
103. Pt. Diagnosed recently w/ dm have not been able to control glucose level during 3 month
what should be done:
Answer: • Check for a1c level
• (other say assess for what she have been eating 3 days ago).

104. When BP is high
Answer: • Administer (lasix)
105. Patient w/ esophaegal varices have not be bleeding for 3 days:
Answer: provide luke warm broth, ice tea and lemon popsicle.
106. Calculo:
Answer: 0.75
107. Pt With Osteomalcia
Answer: Risk For Injury
108. Sbar—Explain Specific Reason For Urgent Notification
Answer: Temperature
109. Intestinal Bowel Obstruction
Answer: Place The Pt 90 Degrees Sitting
110. Osteoarthritis
Answer: Risk For Injury Related To Joint Pain
111. Bone cancer type IV:
Answer: Give Opiods- Non Opiods Analgesics.
112. Hypothyroidism
Answer: Restrict Sodium Na 122
113. Pt arrives to clinic w/ nuchal rigidity fever for 6 hours what to do:
Answer: • Prepare for isolation precautions (I put this one and no lumbar puncture)
114. Intermitent claudication teaching
Answer: • Bandage elastic wraped around legs
• Tambien puede salir como pain traction cast notify md (cast no more then 4hr)

115. Preoperative nursing care
Answer: • Assess emotional preparedness
• Also can be concerns and anxiety for surgery depended la que pongan
116. Trachestomy care:
Answer: Leave old ties on until new ones be on place or secure.
117. Sternal Traction Complains of Pain
Answer: Administer PRN Meds
118. External Fixation
Answer: Administer PRN Meds
119. Multiple Sclerosis (Ms)
Answer: Administer Antimedics/ PRN As Prescribed
120. Female patient how have epigastric pain for 3 days have been Takin antacids and no
resolve arrive to hospital w/hr;128 bpm, bp110/70 what is the most important intervention
finding in assessment:
Answer: Assess For Radiating Jaw Pain.
121. Pt. w. radioactive therapy what to teach/ recommend to
Answer: Protect That Part of The Skin Specially From The Sun
122. Pt with als what to do to prevent respiratory complications:
Answer: Teach Breathing Tecniques, Uses Spirometer, Auscultate For Breath Or Lung
Sounds.
123. PT with left lef ulcer:
Answer: Keep Leg Elevated As Much As He Can.
124. Pt with an external device complaining of pain:
Answer: assess for pheripheral pulses.

125. Calculation 1g/0.4 G
Answer: 2.5
126. Examples of dash diet:
Answer: Peel Fruits And Vegetables.
127. Chest tube w/ a drainage changing from clear to green:
Answer: keep iv fluids.
128. Pt w/ open angle glaucoma select all that apply:
Answer: • Frequent eye exam to asses for vision,
• Use drops to diminish IOP,
• avoid extrenous exercices like jogging or running - ( yo puse solo esas 3 respuestas).
129. Pt w/ hyperthyroidism developing exosphtalmus:
Answer: Prescribe Tear Eye Drops.
130. Pt vomiting blood like the picture same as hematensis:
Answer: • Check vital signs ( asi esta en todos los papeles)
• auscultate lungs sounds ( fue lo que puso yadira)
131. Patient w/ ml fell and when receiving the nurse he have 2 projectile vomits what she do:
Answer: Provide Antiemetics PRN.
132. Pt w/ raynaud syndrome which work as a data entry clerk:
Answer: • Provide a space to warm the enviroment next to her
• (Algo asi era la respuesta). Y hay otra respuesta que solo dice keep monitoring
133. Patient that have the k= 6.7 what medication provide:
Answer: Kayelaxate (Treats Hyperkalemia).
134. Colon Cancer Pt
Answer: Kayelaxate Med

135. Renal injury
Answer: Kayelaxate med
136. Pt with a bronchoscopy and drink a glass of juice :
Answer: Delay The Procedure 6 Hours
137. New patient diagnoses with dm type is receiving teaching in which glucometer will be
the best:
Answer: Assess For Visual Acuity And Ability To Read Or Something Like That.
138. ABG (Ph 7.25 Pco2 50 Sodium 60
Answer: Tachy And Confusion/ Respiratory
139. Acute AGN diet:
Answer: Restrict Na Intake.
140. Pt w/ a expressive aphasia is anger what should do the nurse:
Answer: CVA- Communicate W/ Picture Boards.
141. Nurse is teaching the wife if a patient diagnosed w/ seizure what to do:
Answer: Teach Her How To Position Him
142. Pt after to of something and wants to eat:
Answer: Nurse Assess For Bowel Movements.
143. SLE:
Answer: Assess For Haematuria
144. Patient allergic to banana (latex):
Answer: call to md and or staff to be change everything for synthetic materials,
145. Sub cut emphysema- toracotomy was a select all that apply:
Answer: Assess For Lung Sounds,

146. Neck Distention
Answer: Think It Was And Other Choice That I Not Remember Now.
147. Restless leg syndrome con feosol:
Answer: Assess For Iron And Ferritin.
148. BNP
Answer: Administrative Furosemide Lasix Iv
149. Parkinson Pt Walking
Answer: Reasure That Stepping On Crackles Is Not Harmful
150. Addison Disease
Answer: Take Corticosteroid Meds
151. Carpo Tonic Syndrome
Answer: Wear Brace In Both Wrist
152. Parkinson And Alzaimers Pt
Answer: Taticardic And Confusion
153. Mid Abdomen Burning Pain
Answer: Peptic Ulcer
154. Antibiotics
Answer: Clear Drainage Improve
155. Alloprinol For Gout
Answer: Take Meds Always
156. Blood Transfusion High Temperature
Answer: • Back Pain And Hypotension ( Abo- Low Back Pain And Hypotension)
157. Central Fall Risk

Answer: Cardiovascular Disease
158. Right Hip Fracture
Answer: O2 Sat Level
159. Describe Pain Neuropathy
Answer: Nervous System
160. Acute Abdominal Pain, Nasua, Projectible Vomiting
Answer: Severe Headache And Photo Sensitivity
161. Urolithisis O Lithotripsy Procedure
Answer: Restrict Physical Action
162. UAP ( Dice El Paciente Que Tiene Abd Pain Large Tarry Stool
Answer: Test Stool For Occult Blood
163. Insulin for a glucose level of 255 (Pte tmeblando despues que le pusieron insulin.)
Answer: Obtain capillary glucose.
164. NGT proper tube procedure
Answer: Elevate dead 60 to 90 degree
165. RA (rheuma)
Answer: Impaired peripheral mobility relate to join pain.
166. Finger stick glucose finding 50
Answer: OC Level of conscious
167. BMI (una persona que pueden tener colon cancer)
Answer: • Large waist circumference with central fat

Review for HESI: Recopilation:

168. Community Health/Geriatrics/Professional Issues-Leadership-Geriatric syndrome-home
health
RN needs to go 4 patients and which one needs to see first:
a. The patient discharge yesterday and dehydrated
b. The patient start a new medication and is incontinence
c. The patient that doesn’t want to take a shower
Answer: b. The patient start a new medication and is incontinence
169. Community Health/Medical Surgical-Renal/Reproductive-TURP-home care
The nurse is reinforcing home care instructions with a client who is being discharged
following transurethral resection of the prostate (TURP). Which intervention is most
important for the nurse to include in the clients discharge instructions?
a. Avoid strenuous activity for 6 weeks
b. Report fresh blood in the urine
c. Take acetaminophen for fever 101
d. Consume 6 to 8 glasses of water daily
Answer: b. Report fresh blood in the urine
170. Community Health/Pediatrics/Professional Issues-Leadership/Legal/Ethical-School
nurse role
The school nurse is implementing standards to manage students and provide a safe and
healthy school setting. Which action is most important for the nurse to implement?
a. Maintain student immunization records
b. Develop an emergency plan for the school
c. Ensure that medical supplies are available
d. Conduct annual student health assessments
Answer: a. Maintain student immunization records
171. Community Health/Psychiatric/Mental Health/Fundamentals/Professional
Issues/Medical Surgical-TestBankWorld.org Anxiety/Communications/Basic Nursing
Skills/Safety/Teaching-Infection-communication
A pt with possible pneumonia come to the hospital and the nurse need to do an assessment
but the family don’t want to leave the room, what the nurse need to do first?

a. Call the security
b. Put the family out of the room
c. Put a pneumonia droplet sign in the door
d. Continue with the assessment and put mask to the family
Answer: c. Put a pneumonia droplet sign in the door
172. Critical Care/Fundamentals-Med Administration/Math-IV-mcg/min-dopamine
DOPAMINE 198 LBS 7mcg/kg/minute, 500 mg and 400 ml. ml/hour?
Answer: 47
198:2.2 = 90
7 × 60 × 90 =3 7800mcg
37800mcg:1000 to mlg = 37.8 mlg
500mg:400ml = 1.25
37.8:1.25 = 30.24
173. Critical Care/Fundamentals/Maternity/Pediatrics/Professional Issues-Basic Nursing
Skills/Nutrition/Antepartum/Leadership-Community-primary prevention
A public health nurse receives funding to initiate a primary prevention program in the
community. Which program best fits the nurse’s proposal?
a. Case management and screening for clients with HIV.
b. Regional relocation center for earthquake victims.
c. Vitamin supplements for high-risk pregnant women.
d. Lead screening for children in low-income housing.
Answer: c. Vitamin supplements for high-risk pregnant women.
174. Critical Care/Geriatrics/Medical Surgical-Renal-Acute Tubular Necrosis -GERI
Diabetic, renal no function, decrease urine or not urine, septic shock, check urine specific
Gravity and osmolarity urine.
a. Check urine specific gravity and osmolarity
b. Encourage high protein intake to support renal function
c. Monitor for signs of urine retention and report any oliguria
d. Assess for respiratory rate and oxygen levels to monitor shock status
Answer: a. Check urine specific gravity and osmolarity
Acute Renal Failure: Low Protein

Chronic Renal Failure: NOT Protein at all
Asw possible:Urine claude and check input and output
175. Critical Care/Medical Surgical-Cardiovascular?
Immune/Hematology/Integumentary/Respiratory-MODS-central line placement
NOTE: The Multiple Organ Dysfunction Syndrome (MODS) can be defined as the
development of potentially reversible physiologic derangement involving two or more organ
systems not involved in the disorder that resulted in ICU admission, and arising in the wake
of a potentially life-threatening physiologic insult.
Answer: Shock
176. Fundamentals/Medical Surgical-Basic Nursing Skills-Fluid volume overload
After receiving IV fluids in the emergency department, an elderly client is admitted to the
acute care unit with a medical diagnosis of dehydration. The client is receiving 0.9% normal
saline at 125ml/hr. via a saline lock and has a bounding pulse, tachycardia, and pedal edema.
When contacting the healthcare provider, the nurse anticipates a prescription for what
intervention?
a. Decrease the rate of the normal saline infusion
b. Increase the rate of the normal saline solution
c. Change the IV solution to 0.45 saline solution
d. Remove the saline lock from the client’s arm
Answer: a. Decrease the rate of the normal saline infusion
177. Fundamentals/Medical Surgical-Basic Nursing Skills/Elimination- Acute abdominal
pain
Lower abdominal pain (Order):
a. Position Bent Knees
b. Ask for last food that eat
c. Determine Bowel Movement
d. Inspect Abdominal
e. Auscultate 4 Quadrants
Answer: d. Inspect Abdominal

178. Fundamentals/Medical Surgical-Basic Nursing Skills/Nutrition- Parkinson’s-meals
Provide privacy and give extra time to eat meals and snack OJO
The spouse of a client with Parkinson’s wants to know how to best assist her husband during
feeding as he is having "increasing problems with drooling and swallowing." What
instruction should the nurse provide to the family member?
a. "Use thickened liquids along with upright positioning during feeding."
b. "It might be time to switch to enteral feedings if you are afraid that your husband may
choke."
c. "Increase the amount of fluids he receives to decrease saliva formation and improve
swallowing."
d. "Use a straw during feedings to facilitate swallowing."
Answer: a. "Use thickened liquids along with upright positioning during feeding."
179. Fundamentals/Medical Surgical-Basic Nursing Skills/Nutrition-Visually impairedfeeding-UAP Reloj posisiones manecillas
A patient with chemicals in the eyes and is in the hospital. What the nurse tells to the UAP to
do to help the patient with the food?
a. Give food to the patient in the mouth
b. Indicate to the patient where is the tray (reorient )
c. Look how the patient eat
d. Finger food
Answer: b. Indicate to the patient where is the tray ( reorient )
180. Fundamentals/Medical Surgical-Basic Nursing Huntington’s chorea Skills/Safetya. Padding the side rails of the bed
b. Take the client to the cafeteria to eat
c. Provide extra support when ambulating outside the room
d. Ensure the client is restrained in a chair during meals
Answer: a. Padding the side rails of the bed
181. Fundamentals/Medical Surgical-Basic Nursing Skills/Safety- Hyperglycemia-vomiting
TYPE 1 Diabetes Mellitus Blood Glucose 420 Begins Vomit:
a. Turn the client to a lateral position
b. Obtain a fingerstick glucose

c. Administer insulin as prescribed
d. Assess the client's level of consciousness
Answer: a. Turn the client to a lateral position
182. Fundamentals/Medical Surgical-Basic Nursing Skills/Safety-MRI
A patient scheduled mri and said that has a metal tooth. What the rn need to do?
a. Assess pt fear to the
b. Consults radiology test
c. Send pt to x-ray instead
d. Cancel the test.
Answer: b. Consults radiology test
183. Fundamentals/Medical Surgical-Integumentary/Operative-JP drain full

Postoperative dressing: abdominal wound with jackson pratt drain. What the nurse do first?
(picture)
a. Assess the surgical wound
b. Squeeze
c. empty
Answer: c. empty
184. Fundamentals/Medical Surgical-Med Administration-IV-gravity infusion flow rate
(Question with 4 pictures) Overflow:

a. Arm
b. Arm and Forearm
c. IV Drip
d. IV Regulation
Answer: c. IV Drip
185. Fundamentals/Medical Surgical-Med Administration/Math-IV-Heparin-units Heparin
Sodium 25000 IN 5% 500 ml
a. 46
b. 36
c. 55
d. 12
Answer: b. 36
186. Fundamentals/Medical Surgical-Renal-Diuretic & daily weight
Discharge teaching to a patient with heart failure what parameter is most important for weight
monitoring
The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in
the lower extremities. What instruction should the nurse include in this teaching plan?
a. Stop taking the medication when the edema in the lower extremities subsides.
b. Take the diuretic every day, regardless of weight loss or muscle weakness.
c. Limit fluid intake while taking the diuretic to reduce fluid retention.
d. Weight yourself daily at the same time and report excessive weight loss.
Answer: d. Weight yourself daily at the same time and report excessive weight loss.

187. Fundamentals/Pathophysiology-Basic Nursing Skills/Hygiene/Safety Handwashing
Hand washing:
a. Reduces spread of microorganism. Bio
b. Lock virus
C- Lock in human virus
Answer: a. Reduces spread of microorganism. Bio
188. Fundamentals/Pathophysiology/Professional Issues/Medical Surgical-Basic Nursing
Skills/Nutrition/Teaching-DM2 and CKD-diet
Ketoacidosis Diet
a. Banana, whole bread
b. Oatmeal
c. 6 oz Coffee, strawberry, artificial sweetening
d. Egg, butter
Answer: c. 6 oz Coffee, strawberry, artificial sweetening
189. Fundamentals/Pediatrics-Basic Nursing Skills/Nutrition-infant weight-1-month
At the 1 month old clinic visit, an infants nude weight is 600 gram more that at birth. Which
intervention should the nurse implement?
A. Encourage giving 2 ounces of water between feedings.
B. Recommended ading karo syrup to each forma feeding
C. Document infant’s weight on growth chart
D. Check the infant’s weight using a metric scale.
Answer: C. Document infant’s weight on growth chart
190. Fundamentals/Pediatrics-Med Administration-Oral susp-resisting-PEDI
A child that resists taking the medication:
a. Parents help the nurse holding him
b. Provide the child juice with the medication
c. Explain to the child that if he doesn’t take the medication, he won’t feel better.
Answer: b. Provide the child juice with the medication
191. Fundamentals/Pediatrics-Med Administration/Math-Calculation-PO dose-3x/wk/BSA

The healthcare provider prescribes methotrexate 7.5 mg PO weekly, in 3 divided doses for a
child with rheumatoid arthritis whose body surface area (BSA) is 0.6 m2. The therapeutic
dosage of methotrexate PO is 5 to 15 mg/m2/week. How many mg should the nurse
administer in each of the three doses given week?
a. 3.5
b. 4.5
c. 2.5
d. 5.5
Answer: c. 2.5
192. Fundamentals/Pediatrics-Med Administration/Math-IV-ml/hour-PEDI Vanco
400 mg 6 hours, 100 ml one and half hour
a. 57
b. 67
c. 40
d. 30
Answer: b. 67
193. Fundamentals/Pediatrics/Professional Issues/Medical Surgical-Basic Nursing
Skills/Safety/Leadership-Airborne precautions
Un Nino que los Padres lo llevaron al ER
A. Mandarlo a la casa
B. RN ponerse el precaution
C. Ponerle una mascara al nino.
Answer: B. RN ponerse el precaution
Rationale:
(Isolated room) Airborne precautions: (i). Diseases
a. Measles
b. Chickenpox (varicella)
c. Disseminated varicella zoster
d. Tuberculosis
(ii) Barrier protection
a. Single room is maintained under negative pressure; door remains closed except upon
entering and exiting.

b. Negative airflow pressure is used in the room, with a minimum of 6 to 12 air exchanges p
hour depending on health care agency protocol.
c. Ultraviolet germicide irradiation or high-efficiency particulate air filter is used in the room
d. Health care workers wear mask or personal respiratory protection device.
e. Mask placed on client when client is out of the room; client leaves the room only if
necessary.
194. Fundamentals/Professional Issues-Basic Nursing Skills/Nutrition/Cultural/SpiritualHindu diet
A Hindu patient …. what can the nurse do?
a. Remove beef from pt meal trail
b. Encourage family to bring food from home
c. Show the cardiac menu to the patient
d. Give to the patient what he wants
Answer: c. Show the cardiac menu to the patient
195. Fundamentals/Professional Issues-Med Administration/Documentation-Bar code scanmed administration
When administering a new medication to a client, the nurse uses a scanner to register the
nurse?
a. Use the scanner to register the bar code on the client’s identification bracelet.
b. Document the medication administration on the client’s computerized record.
c. Remove the medication from the unit dose packaging while verifying the dose.
d. Reconcile the medication to be administered with the initial client prescription.
Answer: a. Use the scanner to register the bar code on the client’s identification bracelet.
196. Fundamentals/Professional Issues/Medical Surgical-Basic Nursing
Skills/Nutrition/Teaching- Hypertension diet
A patient with high bp, the nurse give a teaching for what can he eat for lunch?
a. Tomato Juice And Gluten Free Crackers
b. Baked Sweet Potato
c. Carrot
d. Radish
Answer: b. Baked Sweet Potato

197. Fundamentals/Professional Issues/Medical Surgical-Basic Nursing
Skills/Safety/Teaching-Influenza precautions
Patient with influenza. Dehydrated and pneumonia:
a. Droplet precaution
b. Family member wear mask
c. Skill
d. power
Answer: a. Droplet precaution
NOTE: Droplet precautions should be implemented for patients with suspected or confirmed
influenza for 7 days after illness onset or until 24 hours after the resolution of fever and
respiratory symptoms, whichever is longer, while a patient is in a healthcare facility.
198. Fundamentals/Professional Issues/Medical Surgical-Med Administration/TeachingInsulin adm-teaching 1
(PICTURE)

The nurse shows the mom of the child how to use insulin for the child that is diabetic:
a. Assist The Mother In
b. The Correct Angle
c. Locating The Correct Site or assess
Answer: c. Locating The Correct Site or assess
Rationale:

45 angle pen 90 angle
199. Fundamentals/Professional Issues/Medical Surgical-Teaching-Pursed lip breathing 2
Answer: VIDEO *Pursed lip Breathing: IN and OUT (Inhale through the nose and exhale by
mouth)
200. Geriatrics/Medical Surgical-Integumentary-Skin care-GERI
An older male resident of a long-term care facility has been scratching his legs for the past 2
days. Which intervention should the nurse implement?
a. Explain the importance of bathing or showering daily.
b. Keep the legs covered as much as possible.
c. Apply emollient to affect area at least twice daily.
d. Encourage fluid intake of at least 2, 000 ml daily.
Answer: c. Apply emollient to affect area at least twice daily.
201. Maternity–Antepartum –Fetal stress - Tachycardia
The nurse is assessing a primigravida at 39-weeks gestation during a weekly prenatal visit.
Which finding is most important for the nurse to report to the healthcare provider?
a. Reports intermittent low back pain.
b. Fetal heart rate of 200 beats/minutes
c. Complains of early morning heartburn
d. Maternal hemoglobin of 11.0 g/ dl or 110 g/l (SI)
Answer: b. Fetal heart rate of 200 beats/minutes
*Note: Normal FHR pregnant women: 120-160
202. Maternity – Intrapartum – Intrapartum pain management
Pregnant women with 8 cm de dilatation y 100%, she wants to get hydrochloride (don’t
remember the exactly name) for pain:
a. administer epidural
b. administer hydrochloride
c. relaxation technique
Answer: c. relaxation technique
203. Maternity – Postpartum – Hemorrhage postpartum Possible

Answer: Check for clots and lochia
204. Maternity – Postpartum – Priority management-postpartum
After receiving shift report, the nurse working on a postpartum unit should assessment first?
a. Vaginal birth today whose infant is refusing to breastfeed.
b. Cesarean birth of twin today who is new complaining of pain.
c. Post-cesarean birth today with fundus at the umbilicus.
d. Multipara vaginal birth yesterday saturating two pads hours.
Answer: d. Multipara vaginal birth yesterday saturating two pads hours.
205. Maternity/Medical Surgical – Antepartum – Barbiturates & pregnancy
The nurse is evaluating medication teaching. Which statement by a female who takes a
barbiturate for sleep indicates she understands the teaching?
a. “I should ensure that I do not become pregnant while taking this medication.”
b. “I must take my birth control pill in the morning and my sleeping pill at night.”
c. “I will increase the amount I take in small doses if I can’t sleep through the night.”
d. “I should take my anxiety pill, alprazolam, only when I really need it.”
Answer: a. “I should ensure that I do not become pregnant while taking this medication.”
206. Maternity/Medical Surgical –Postpartum –Post vaginal delivery- diaphragm
Patient that had a vaginal birth, diaphragm. What teaching the nurse need to give to the
patient?
a. 2 or 6 hours before intercourse
b. Re-adapt
c. Resisted diaphragm
d. Is no anti-concretive
Answer: c. Resisted diaphragm
207. Maternity/Professional Issues-Antepartum/Cultural/Spiritual-Pregnancy-cultural
awareness
Pregnant women first prenatal visit at 12 weeks
a. Concern about delivery
b. Parenting
c. Complication during pregnancy

d. childhood
Answer: d. childhood
208. Maternity/Professional Issues-Antepartum/Leadership-BPP-fetal wellbeing
Four clients arrive on the labor and delivery unit at the same time. Which client should the
nurse assess first?
a. A 41-week multigravida who is scheduled induction of labor today.
b. A 38-week primigravida who reports contractions occurring every 10 minutes.
c. A 36-week multigravida with a prescription for serial blood pressure.
d. A 39-week primigravida with biophysical profile score of 5 out of 8
Answer: d. A 39-week primigravida with biophysical profile score of 5 out of 8
209. Medical Surgical-Cardiovascular-Angina-exercise
A male client with angina pectoris is being discharged from the hospital. What instructions
should the nurse plan to include to the discharge teaching?
a. Engage in physical exercise immediately after eating to help decrease cholesterol levels.
b. Walk briskly in cold weather to increase cardiac output.
c. Keep nitro glycerin in a light-colored plastic bottle and readily available.
d. Avoid all isometric exercises, but walk regularly.
Answer: d. Avoid all isometric exercises, but walk regularly.
210. Medical Surgical-Cardiovascular-Arterial sheath Saunder 791
Arterial sheath : Pedal pulses and colour, warmth movement and sensation of affected leg &
foot Asses insertion site for bleeding, pain, tenderness, swelling or haematoma. No levantarse
hasta despues de 8 hrs
A patient recovering left femoral atrial sheath. What finding requires immediate intervention
(Select all that apply?)
a. Tenderness on insertion site
b. Left groin egg size
c. Quarter size of drainage
d. Unrelieved back, flank pain
e. Cool/pale left foot
Answer: a. Tenderness on insertion site
e. Cool/pale left foot

211. The nurse in the outpatient unit is caring for a client who had a right femoral cardiac
cauterization two hours ago .What assessment findings requires immediate intervention?
a. The client wants assistance walking to the bathroom
b. Clients pulse oximeter is 98%
c. The client right feed is warn to touch
d. The client B/P is 110/70 and pulse 90
Answer: a. The client wants assistance walking to the bathroom
212. Medical Surgical-Cardiovascular-Atenolol
The healthcare provider prescribes atenolol 50 mg PO daily for a client with angina pectoris.
Which finding should the nurse report to the healthcare provider before administering the
medication?
a. Chest pain.
b. Urinary frequency.
c. Tachycardia.
d. Irregular pulse.
Answer: d. Irregular pulse.
213. Medical Surgical-Cardiovascular-Atrial fibrillation-assess
Answer: Atrial fibrillation, or A-Fib, is the most common heart rhythm disorder in the United
States. It’s a condition in which the electrical impulses that control muscle contractions in the
upper chambers of the heart become rapid and chaotic. About 160, 000 new cases of A-Fib
are diagnosed in the U.S. each year–but physicians believe that many people who have A-Fib
have not been diagnosed.
The likelihood of developing A-Fib increases with age. The majority of people diagnosed
with A-Fib are 55 or older. Between three and five percent of people over age 65 and nine
percent of people over the age of 80 have A-Fib.
Diagnosing and treating A-Fib are important because, left untreated, it can lead to a number
of serious heart conditions. Patients with A-Fib are also five times more likely to suffer a
stroke. (Although you should see a doctor to diagnose A-Fib, one way to help asses your risk
is to take your pulse. Click here for a step-by-step guide–or watch Archie Manning show how
it’s done.)

One complicating factor is that the signs and symptoms of A-Fib can vary greatly from
patient to patient. Some people experience a sudden heart flutter or tremor, or feel their heart
“speed up” suddenly; other patients with A-Fib may not feel anything at all. Other symptoms
can include:
Shortness of breath
Fatigue
Weakness or difficulty exercising
Chest pain
Sweating
Dizziness
Fainting
A-Fib is not an emergency–but it is a serious condition. If you suspect you have A-Fib you
should see your doctor immediately. Contact your primary care doctor–or find a St.Vincent
doctor near you. Or make an appointment to see an A-Fib specialist at the St.Vincent A-Fib
Center of Excellence. We can discuss the many treatment options available to treat and cure
A-Fib–and help choose the one that’s right for you.
214. Medical Surgical-Cardiovascular-BP-variance in arms
Answer: Change the arm or wait 5 min and change the arm
215. Medical Surgical-Cardiovascular-High BP-vasoconstriction
A patient is diagnosed with MALIGNANT HYPERTENSION, patient likes skiing and asks if
is ok to continue:
a. “Cold weather may constrict your blood vessels and increase bp”
b. “Skiing Might Produce Too Much Exertion”
c. “Should Be Ok As Soon As You Confine Skiing
d. “Go For It Is A Terrific Workout
Answer: a. “Cold weather may constrict your blood vessels and increase bp”
216. Medical Surgical-Cardiovascular-Pitting edema 4+
Answer:

217. Medical Surgical-Cardiovascular-SVT-cardioversion-priority Electro shock
Answer: synchronic
218. Medical Surgical-Cardiovascular/GI/Hepatic-Bariatric surgery-abd pain
A patient get to ER and had a week before a bariatric surgery, patient is shortness of breath
and has abdominal pain.
a. Blood pressure 88/50
b. Left shoulder pain
c. Sustained sinus tachycardia
d. 101 temperature
Answer: a. Blood pressure 88/50
219. A woman who had bariatric surgery 2 months ago is admitted because of vomiting and
inability to tolerate food and liquids. She states that she is pain free. Which intervention
should the nurse include in the client’s plan of care?
a. Maintain the client on a NPO status
b. Administer daily vitamin supplements
c. Determine if the client is over-hydrating to feel satiated
d. Encourage positive self-accolades for dietary adherence
Answer: a. Maintain the client on a NPO status
220. Medical Surgical-Cardiovascular/Physical Assessment-Carotid bruit

Answer:

221. Medical Surgical –Cardiovascular/Renal-Lasix-outcome PEDI Child taking Lasix.
Nurse look for effective of the medicine:
Answer: Lose 2 pounds weekly
222. Medical Surgical-Cardiovascular/Trauma/Emergency-Unstable angina
Unstable angina is more intense that stable angina. Make a pt awake when they sleep. Made
more that 5 min no relies by nitroglycerin. Is a stereo sclerotic plaque rupture. Thrombus
formation MI. No always we can see in a elevated ST changes.
Stable angina is realize with nitroglycerin and relaxation .

Client was admitted to the cardiac observation unit 2 hour ago complaining of chest pain .On
admission the client EKG showed bradycardia , ST depression , but no ventricular ectopic
.The client reports a sharp pain , telling the nurse , I feel like an elephant just stepped on my
chest The EKG now shows Q waves and ST elevations in the anterior leads .What
intervention should the nurse perform ?
a. Administer prescribed morphine sulfate IV and provide oxygen at 2L per minute per nasal
cannula
b. Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzyme levels
c. Notify the HCP of the clients increased chest pain and call for defibrillator crash cart
d. Increased the peripheral IV rate to 175 ml/hr. to prevent hypotension and shock
Answer: a. Administer prescribed morphine sulfate IV and provide oxygen at 2L per minute
per nasal cannula
223. Medical Surgical-Endocrine-Chvostek’s sign-tetany-POC
The nurse is caring for a client with hyperparathyroidism. Which assessment should the nurse
include the plan of care?
a. Chvostek’s sign
b. Brudzinski’s sign.
c. Battle’s sign.
d. Pupillary response.
Answer: a. Chvostek’s sign
224. Medical Surgical-Endocrine-Diabetes-acute confusion
A female client with pancreatic cancer is NPO for implantation of a venous sedation.
Suddenly, the client becomes unresponsive, and her skin is cool pulse 96 beats/minute,
respiratory rate 18 breaths/minute, which are within her outpatient surgery nurse implement
first?
a. Administer glucagon 0.5 mg IM
b. Infuse a 200 ml NS IV fluid bolus
c. Obtain a finger stick blood glucose
d. Insert a second peripheral IV catheter
Answer: c. Obtain a finger stick blood glucose

225. Medical Surgical-Endocrine-DKA-IV
Answer: IV insulin: Trade hydration with rapid IV infusion 0.9 a 0.45 normal saline as
prescriber, because can elevated edema.
Intravenous fluid replacement should start immediately with 1 to 2 L of normal saline over
the first 1 to 2 hours of treatment for adults. In children the initial fluid bolus is weight based
(5 to 20 mL/kg, dependent on the child’s perfusion status); volume replacement is carefully
titrated because of the high risk for cerebral edema in the pediatric population. The adult
patient may require up to 8 to 10 L of fluid. Volume is gradually replaced after the initial
fluid bolus because rapid infusion of a large volume increases the risk for development of
cerebral edema. Close observation of intake and output is essential; placement of a urinary
catheter ensures accurate output assessment. A continuous infusion of regular insulin is
administered at 0.1 units/kg/hr to stop ketogenesis and achieve a steady decrease in serum
glucose level of 50 to 75 mg/dL/hr; an initial intravenous (IV) bolus of 0.15 units/kg of
regular insulin may be administered. The short duration of action for regular insulin allows
better control of serum glucose levels. After serum glucose level reaches 250 to 300 mg/dL,
fluids should be converted to 5% dextrose in normal saline (D5NS) to provide fuel until the
patient is able to eat. Resolution of a hyperglycemic emergency occurs when the serum
glucose level is less than 200 mg/dL, serum bicarbonate level is greater than or equal to 18
mEq/L, and in DKA, the venous pH is greater than 7.3.[3]
Fluid replacement dilutes serum potassium and promotes diuresis. In addition, total body
hypokalemia is exacerbated by metabolic acidosis, so potassium replacement should begin
after the initial liter of IV fluids is infused, even when initial values are normal. Potassium
levels frequently drop precipitously in the first few hours after treatment has been initiated
because potassium moves back to the intracellular space along with the insulin and existing
glucose. Serum potassium levels must be repeated every 1 to 2 hours during initial
management. Cardiac monitoring is essential because dysrhythmias can develop with
significant hypokalemia.
Acidosis generally corrects with insulin therapy. Insulin allows the cells to use available
glucose for energy, leading to decreased proteinolysis and lipolysis, and the ketoacidosis
resolves. Insulin infusion should be continued until the pH or serum bicarbonate level has
normalized; IV fluids should be converted to D5NS once the serum glucose level reaches 250
to 300 mg/dL to prevent hypoglycemia. Acidosis in DKA is not routinely treated with sodium
bicarbonate because sodium bicarbonate administration can cause rebound alkalosis, which
can worsen hypokalemia and increases the risk for development of cerebral edema.

Controlling nausea and vomiting not only improves patient comfort but prevents worsening
dehydration. The patient may require analgesia to relieve abdominal pain, headaches, or other
somatic complaints. Providing a quiet, calm environment can improve patient comfort. Stress
reduction plays an important part in patient recovery. Thorough explanation of treatment,
medications, and plan of care can alleviate stress related to hospitalization.
Potential complications include hypoglycemia, hypokalemia, dysrhythmias, and cerebral
edema. Monitor capillary/serum glucose levels, electrocardiogram (ECG), laboratory values,
vital signs, intake and output, and neurologic status carefully. If the serum glucose level falls
rapidly, the resulting fluid shift can lead to cerebral edema, which is associated with a higher
mortality rate. Cerebral edema remains the leading cause of death for children presenting in
DKA.
226. Medical Surgical-Endocrine/GI/Hepatic-Acute pancreatitis
Answer: Pancreatitis
The pancreas is an organ located behind the stomach that produces chemicals called enzymes,
which are needed to digest food. It also produces the hormones insulin and glucagon. Most of
the time, the enzymes are only active after they reach the smal l intestine
When these enzymes become active inside the pancreas, they digest the tissue of the
pancreas. This causes swelling, bleeding (hemorrhage), and damage to the organ and its
blood vessels . This condition is called acute pancreatitis . Acute pancreatitis affects men
more often than women. Certain diseases, surgeries, and habits make you more likely to
develop this condition. The two most common causes of pancreatitis in the United States are
heavy alcohol use and gallstones.
Alcohol use is responsible for up to 70% of cases in the United States. Acute pancreatitis
typically requires 5 to 8 drinks per day for 5 or more years.
Gallstones are the next most common cause. The condition develops when the gallstones
travel out of the gallbladder into the bile ducts, where they block the opening that drains the
common bile duc t and pancreatic duc t (ampulla). Genetics may be a factor in some cases.
Sometimes, the cause is not known. Other conditions that have been linked to pancreatitis
are:
• Autoimmune problems (when the immune system attacks the body)
• Damage to the ducts or pancreas during surgery
• High blood levels of a fa t called triglycerides (hypertriglyceridemia) usually above 1000
mg/dL

• Injury to the pancreas from an accident Other causes include:
• Complications of cystic fibrosis
• Hemolytic uremic syndrome
• Hyperparathyroidism
• Kawasak i disease
• Reye syndrome
• Use of certain medications (especially estrogens, corticosteroids, sulfonamides, thiazides
and azathioprine)
• Viral infections, including mumps, coxsackie B, mycoplasma pneumonia , and
campylobacter
• Injury to the pancreas after a procedure such as an ERCP (endoscopic retrograde
cholangiopancreatography ) or EUS (endoscopic ultrasound) with FNA (fine needle aspirate)
Symptoms
The main symptom of pancreatitis is pain felt in the upper left side or middle of the abdomen.
The abdominal pain:
• May be worse within minutes after eating or drinking at first, especially if foods have a high
fa t content
• Becomes constant and more severe, lasting for several days
• May be worse when lying flat on the back
• May spread (radiate) to the back or below the left shoulder blade
People with acute pancreatitis often look ill and have a fever, nausea, vomiting, and sweating.
Other symptoms that may occur with this disease include:
• Clay-colored stools
• Gaseous abdomina l fullness
• Hiccups
• Indigestion
• Mild yellowing of the skin and whites of the eyes (jaundice)
Swollen abdomen
227. Medical Surgical-Endocrine/Integumentary-DM cellulitis 3 eval
Answer: Cellulitis is a deep infection of the skin that extends to the subcutis. It begins as a
painful, tender, erythematous, warm area that spreads rapidly and produces indistinct borders.
Fever, chills, rigors, and sweats are frequent. The infection most often begins at the site of

antecedent trauma, which may be minor or major. It may also occur as a result of infection
associated with closure of non-sterile wounds and at the site of sutures. Cellulitis frequently
extends via the lymphatic system and can produce lymphangitis, lymphadenopathy,
abscesses, and bacteremia.
While taking antibiotics, monitor your condition to see if symptoms improve. In most cases,
symptoms will improve or disappear within a few days. In some cases, pain relievers are
prescribed. You should rest until your symptoms improve. While you rest, you should raise
the affected limb higher than your heart to reduce any swelling.
228. Medical Surgical-GI/Hepatic-GERD-antacid
An antacid is prescribed for a client with gastro esophageal reflux (GERD). The client asks to
the nurse, “How does this help my GERD? What is the best response by the nurse?
A. “Ant acids decrease the production of gastric secretions.”
B. “It will improve the emptying of food through your stomach.”
C. “This medication will coat the lining of your esophagus.
D. “Antacids will neutralize the acid in your stomach.”
Answer: D. “Antacids will neutralize the acid in your stomach.”
229. Medical Surgical-GI/Hepatic/Neurological-Lactulose
Answer: Lactulose
230. Medical Surgical-GI/Hepatic/Respiratory-EGD-recovery care
Following an esophagogastroduodenoscopy (EGD), a make client is drowsy and difficult to
and his respiratory are slow and shallow. Which action should the nurse implement (Select all
that apply?)
a. Initiate bag valve-mask ventilation.
b. Prepare medication reversal agent.
c. Apply oxygen via nasal cannula.
d. Check oxygen saturation level.
e. Begin cardiopulmonary resuscitation.
Answer: b. Prepare medication reversal agent.
c. Apply oxygen via nasal cannula.
d. Check oxygen saturation level.

231. Medical Surgical-Immune/Hematology-Blood transfuse reaction
A client receiving a blood transfusion complains of itchy skin and appears flushed. What
action should the nurse take first?
a. Check the blood type on the bag
b. Notify the healthcare provider
c. Assess the client’s temperature
d. Stop the blood transfusion.
Answer: d. Stop the blood transfusion.
232. Medical Surgical-Immune/Hematology/Integumentary-Sunburn-severe reaction
Pt expuesto al sol y no se puso sunblock and blisters. Que s/s vas a ver.
Answer: • headache
• No es chills and fever
• Signs of Sunburn. When you get a sunburn, your skin turns red and hurts. If the burn is
severe, you can develop swelling and sunburn blisters. You may even feel like you have the
flu -- feverish, with chills, nausea, headache, and weakness.
233. Medical SurgicalImmune/Hematology/Integumentary/Trauma/Emergency-Dog bite-adult
An adult arrives at the urgent care clinic after being bitten on the hand by an aggressive dog
that escaped from a neighbor’s fenced yard. The nurse cleanses the wound with providoneiodine and administers Human Rabies Immune Globulin (HRIG) and the first injection of the
rabies vaccine. Which intervention is most important for the nurse to implement?
a. Determine if the client has any allergies to antibiotics.
b. Send client for a magnetic resonance image (MRI) of the hand
c. Schedule administration of remaining rabies vaccine injections
d. Notify local Animal Control Bureau about the dog bite
Answer: c. Schedule administration of remaining rabies vaccine injections
234. Medical Surgical-Immune/Hematology/Musculoskeletal-Myasthenia gravis-findings
myasthenia gravis taking (mestinon). what finding requires intervention by the nurse?
a. eyelid drooping
b. tingling extremities
c. uncontrolled drooling

Answer: c. uncontrolled drooling
235. Medical Surgical-Integumentary-Rule of nines-estimate

Patient with burns. What percent?
a. 36%
b. 27%
c. 50%
d.16%
Answer: b. 27%
236. Medical Surgical-Integumentary/Reproductive-Burns-monitor
A client with superficial burns to the face, neck, and hands resulting from a house fires is
admitted to the burn unit. Which assessment finding indicates to the nurse that the client
should he monitored for carbon monoxide poisoning?
a. Expiratory stridor and nasal flaring
b. Mucous membranes cherry red color
c. Carbonaceous particles in sputum
d. Pulse oximetry reading of 80 percent.
Answer: b. Mucous membranes cherry red color

237. Medical Surgical –Musculoskeletal-Fat embolism-S&S hesi pg 134
Fat embolism: A process by which fat tissue passes into the bloodstream and lodges within a
blood vessel.
Signs and symptoms: include central nervous system dysfunction that may progress to coma
or death, irregularities in the heartbeat, respiratory distress, and fever. Anemi a and
thrombocytopeni a (low platelet count) are common. Commonly, small hemorrhages are seen
on the neck, shoulders, armpits, and conjunctiva.
Answer: Low fever
238. Medical Surgical-Musculoskeletal-Gout-stress management
Which expected outcome statement should the nurse include in a teaching plan of care. A
client with management of an acute attack of gout?
a. The client will avoid use of alcohol in managing stress
b. The client will implement a high purine daily dietary regimen
c. The client will use local heat application for acute pain
d. The client will stop antigout medication once pain subsides
Answer: a. The client will avoid use of alcohol in managing stress
239. Medical Surgical-Musculoskeletal-RA-pain management
Patient with rheumatoid arthritis joint pain and swelling, taking prednisone and ibuprofen,
self management pain what information obtain
a. Presence of bruising, weakness
b. Amount of protein
c. Therapeutic exercise daily
d. Existence GI discomfort
Answer: c. Therapeutic exercise daily
240. Medical Surgical-Musculoskeletal-Risendronate teaching
Which instruction is most important for the nurse to provide a client who receives a
prescription for risendronate sodium to treat osteoporosis?
a. Remain upright after taking the medication.
b. Begin a weight-bearing exercise plan.
c. Increase intake of foods rich in calcium.

d. Schedule a bone test every year.
Answer: a. Remain upright after taking the medication.
241. Medical Surgical-Neurological-Alzheimer’s-safe
In planning care for a client with early stage Alzheimer’s disease, the nurse establishes the
nursing diagnosis of, “Risk for injury related to impaired judgment.” Which intervention is
most important for the nurse to include in this client’s plan of care?
a. Offer the client frequent reassurance that he/she will be safe.
b. Assign a UAP to provide the client with total personal care.
c. Engage the client in regularly scheduled activities during the day.
d. Arrange the client’s environment so the client can move about freely.
Answer: d. Arrange the client’s environment so the client can move about freely.
Rationale:
If the client is aggressive you can use the wrist with doctor’s authorization
242. Medical Surgical-Neurological- Cervical cord injury
Answer: • Sharp pain
• Symptoms of a spinal cord injury may include:
• Head that is in an unusual position
• Numbness or tingling that spreads down an arm or leg Weakness
• Difficulty walking
• Paralysis (loss of movement) of arms or legs
• Loss of bladder or bowel control
• Shock (pale, clammy skin; bluish lips and fingernails; acting dazed or semiconscious)
• Lack of alertness (unconsciousness)
• Stiff neck, headache, or neck pain
243. Medical Surgical-Neurological-Increased ICP-papilledema
Patient involves in an accident….which indicate increase of ICP:
a. Nuchal rigidity/dystonia
b. Confusion/papilledema
c. Periorbital eccymocis
d. Increase Glasgow scale
Answer: b. Confusion/papilledema

244. Medical Surgical-Neurological/Physical Assessment-Pupil constriction
Answer: Pupila accommodation
245. Medical Surgical –Neurological /Sensory-Pregabalin
Peripheral neuropathy Pregabalin 4 days, what indicate med is effective?
a. granulating tissue in foot ulcer
b. improved visual acuity
c. full volume of pedal pulses
d. reduce level of pain
Answer: d. reduce level of pain
246. Medical Surgical –Oncology/Physical Assessment –Lymphatic cancer
The nurse is palpating the lymph nodes of a 10 month old. Which findings should the nurse
call to the attention of the health care provider?
a. Enlarged, warm, tender preauricular node
b. Enlarged no tender mobile occipital node
c. Small discrete, mobile, no tender, inguinal node
d. Small, firm, mobile nodules in the axial
Answer: a. Enlarged, warm, tender preauricular node
247. Medical Surgical-Oncology/Reproductive-Breast cancer findings
A female client with breast cancer who completed her first chemotherapy treatment outpatient cancer treatment center is preparing for discharge. Which behavior the client
understands her care needs for the next week?
a. Invite friends and family to visit while she is at home for the next week
b. Rent movies and borrow books to use while passing time at home
c. Schedule a lunch date with her best friend for 2 days from now
d. Stock her refrigerator with healthy foods including fruits and vegetables
Answer: b. Rent movies and borrow books to use while passing time at home
248. Medical Surgical-Operative-OR-supine position
A patient surgery for more than 2 hours, what implementation or intervention?
Answer: Put padding to the bony prominences

249. Medical Surgical-Operative-Postop-ambulation
At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the
client’s medical record. Based on data contained in the record, what action should the nurse
take before assisting the client with ambulation (click on each chart tab for additional
information, be sure to scroll to the bottom right corner of each tab to view all information
contained in the client’s medical record)
a. Remove sequential compression devices
b. Apply PRN oxygen per nasal cannula
c. Administer a PRN dose of an antipyretic
d. Reinforce the surgical wound dressing
Answer: a. Remove sequential compression devices
250. Medical Surgical-Physical Assessment-Pain assessment Assessing client’s pain:
a. “Tell me more about how you respond to pain.”
b. “On a scale of 1 to 10, how much pain are you in?”
c. “Are you sure you are in pain?”
d. “Do you want me to give you something for your pain?”
Answer: a. “Tell me more about how you respond to pain.”
251. Medical Surgical-Physical Assessment/Respiratory-Pneumonia-priority assessment
Patient with pneumonia ABG ph 7.24, CO2 65, CO3 24. Which intervention …. plan of care
daily
a. Hypertension
b. Maintain IV
c. Check electrocardiogram daily
d. Assess lung for increase pulmonary secretion
Answer: d. Assess lung for increase pulmonary secretion
252. The nurse is preparing to administer an oral antibiotic to a client with unilateral
weakness, mouth drooping, and aspiration pneumonia. What is the priority nursing
assessment that she will be done before administering the medication.
a. Determine which side of the body is weak
b. Auscultate and breathe sounds

c. Obtain and record client vital sign
d. Ask the client about soft food preferences
Answer: a. Determine which side of the body is weak
253. Medical Surgical-Renal-Acute kidney injury (AKI)-POC
A female client with chronic pyelonephritis expresses concern that she may have to undergo
dialysis. What is the best initial response by the nurse?
a. Offer to introduce the client to a dialysis nurse who can provide teaching about dialysis
b. Explain the relationship between chronic kidney infection renal failure and dialysis
c. Provide assurance that dialysis is not the usual treatment for kidney infections
d. Assist the client to reduce anxiety and gain control by using guided imagery exercise
Answer: b. Explain the relationship between chronic kidney infection renal failure and
dialysis
254. Medical Surgical-Renal-Chronic renal insufficiency
Which symptoms is a characteristic of urethral colic in the client diagnosed with renal
calculi?
a. symptoms of irritation associated with urinary tract infection
b. Acute, excruciating pain, wave-like pain radiating to the gemnitalia
c. intense, deep ache in the cost vertebral region
d. chills, fever and dysuria
Answer: b. Acute, excruciating pain, wave-like pain radiating to the gemnitalia
255. Medical Surgical-Reproductive-Endometriosis
A young adult female client with recurred pelvic pain for 3 years returns to the clinic for
relief of severe dysmenorrheal. The nurse reviews her medical record
which indicates that the client has endometriosis. Based on this finding, what information
should the nurse provide this client?
a. Oral contraceptives increase the symptoms of endometriosis
b. An option to diagnose disease extent and provide therapeutic treatment is laparoscopy
c. Infertility is successfully treated with removal of intra-abdominal endometrial lesions
d. The symptoms of endometriosis can increase with menopause
Answer: b. An option to diagnose disease extent and provide therapeutic treatment is
laparoscopy

256. Medical Surgical-Respiratory-Chest tube-respiratory distress
The UAP find a patient (chest tube) with shortness of breath call the RN. What is the first
thing that the nurse implements?
a. 2 L Oxygen
b. Check the tube connection
c. Nitrous
Answer: b. Check the tube connection
257. Medical Surgical-Respiratory-Pulmonary function test
A client with a 40 pack year history of smoking does not want to have a pulmonary function
test conducted. Which of the following should the nurse explain to the client regarding this
diagnostic test?
a. ¨It is used to diagnose lung cancer so treatment can be started
b. ¨It is used to determine the amount of oxygen that is in your lungs with every breath¨.
c. ¨It measures your lung functioning¨.
d. ¨It identifies the best interventions to help you quit smoking.
Answer: c. ¨It measures your lung functioning¨.
258. Medical Surgical-Respiratory-TB precautions
Answer: Airborne Precaution
259. Medical Surgical-Respiratory-TB activated
A male client recently release from a correctional facility arrives at the clinic with a cough,
fever, and chills, active tuberculosis (TB) 10 years ago. What action should the nurse
implement? (Select all that apply)
a. Administer a purified protein derivate (PPD) test
b. Schedule the client for a chest radiograph
c. Obtain sputum for acid fast bacillus (AFB) testing
d. Place a mask on the client until he is moved to isolation
e. Send client home with instructions for a prescribed antibiotic
Answer: b. Schedule the client for a chest radiograph
c. Obtain sputum for acid fast bacillus (AFB) testing
d. Place a mask on the client until he is moved to isolation

260. Medical Surgical-Sensory-Cataract extraction-nausea
Answer: Zofran Or Antiemetic
261. Medical Surgical-Sensory-Pilocarpine-action
A client is newly diagnosed with open-angle glaucoma and receives a prescription for the
meiotic pilocarpin. The client asks how the eyes pressure will be controlled when the eyes
drops are used on the surface. What explanation should the nurse offer when teaching about
the therapeutic action of the ophthalmic drops?
a. Once the pupil gets smaller, the amount of liquid made inside the eyes is reduced
b. It is necessary to open the pupil to allow movement of the fluid from behind the iris
c. The drops will reduce eye swelling which is causing increased ocular pressure
d. The iris will constrict and contract away from the opening, thereby allowing
it to drain
Answer: d. The iris will constrict and contract away from the opening, thereby allowing
it to drain
262. Pathophysiology-Neurological/Physical Assessment-Craniotomy-GCS When assessing a
client who had a supratentorial craniotomy, what action should the nurse implement when
determining the client’s Glasgow coma scale (GCS) rating?
a. Determine the intracranial pressure.
b. Check the patellar and radial reflexes.
c. Inject cold water into the client’s ear.
d. Instruct the client to raise an arm.
Answer: d. Instruct the client to raise an arm.
263. Pathophysiology/Medical Surgical-Immune/Hematology-Antihistamines Which
conditions are most likely to respond to the treatment with antihistamines? (Select all that
apply)
a. Otitis media
b. Allergy rhinitis
c. Contact dermatitis
d. Myocarditis
e. Bronchitis

Answer: b. Allergy rhinitis
c. Contact dermatitis
264. Pathophysiology/Medical Surgical-Immune/Hematology-WBC levelpatho
A female adult who is undergoing chemotherapy tells the nurse that she plans to volunteer at
elementary school this winter. Which question is best for the nurse to ask this client?
a. “Do you realize that you will be exposed to many different kinds of germs?”
b. “Have you considered that you are putting yourself at risk for developing infections?”
c. “Are you aware that you do not have a fully functioning immune system?”
d. “Is it possible that you will be in direct contact with the children at the school?”
Answer: b. “Have you considered that you are putting yourself at risk for developing
infections?”
265. A client’s morning laboratory test results include leukocytes 3, 500/mm3 or 3.5 x 109/L
(SI). Based on this laboratory result, which complaint is this client most likely to report to the
nurse?
a. Inability to walk without shortness of breath.
b. Superficial cuts do not readily stop bleeding.
c. A red streak and pain in right calf muscle
d. Persistent cough with yellow-colored sputum.
Answer: d. Persistent cough with yellow-colored sputum.
266. Pathophysiology/Medical Surgical-Musculoskeletal-Osteoarthritis-risk factor
The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis.
Which factor in the client’s history is a contributor to the osteoarthritis?
a. Lactose intolerant since childhood.
b. Recently treated for deep vein thrombosis.
c. Long distance runner since high school.
d. Photosensitive to a drug currently taking.
Answer: c. Long distance runner since high school.
267. Pathophysiology/Medical Surgical-Neurological/Trauma/Emergency-Head injurydiabetes insipidus

Answer: Polyuria can be defined as a urine output exceeding 3 L/24 h in adults and 2 L/m2
in children. It must be differentiated from the more common complaints of frequency or
nocturia, which are not associated with an increase in the total urine output. Differential
diagnosis has to be kept in mind when TBI patients undergoing neurosurgery have huge
amounts of urine output because most cases of polyuria, at this time, are not caused by DI
(Seckl and Dunger 1989). The more common causes are excretion of excess fluid
administered during surgery and an osmotic diuresis, resulting from treatment aimed at
minimizing cerebral edema using mannitol or glucocorticoids (Bohn, Davids et al. 2005).
268. Pathophysiology/Professional Issues/Medical Surgical-Nursing Process-Resp acidosispneumonia
Pneumonia is diaphoretic and confused:
Answer: Observe Frequently
269. A client with a history of upper respiratory symptoms is admitted to the unit with chest
tightness, productive cough and difficult breathing. The client ABG is respiratory acidosis.
What lab the nurse expects to be high?
a. PH
b. Arterial pH.
c. HCO3
d. PaCO2
Answer: d. PaCO2
270. Pediatrics-Cardiovascular-Left sided heart failure
A nurse is assessing a 2 year-old child with left sided heart failure. Which assessment finding
should the nurse report to the healthcare provider immediately?
a. Penorbital edema noted bilaterally after napping
b. Crackles heard in lower lobes of lungs bilaterally
c. An apical heart rate of 120 beats per minute
d. Liver palpated 2 cm below right costal margin
Answer: b. Crackles heard in lower lobes of lungs bilaterally
271. Pediatrics-GI/Hepatic-Diarrhea-specimen
Answer: Stool Specimens

Stool specimens are frequently collected in children to identify parasites and other organisms
that cause diarrhea, to assess gastrointestinal function, and to check for occult (hidden) blood.
Ideally, stool should be collected without contamination with urine, but in children wearing
diapers this is difficult unless a urine bag is applied. Children who are toilet trained should
urinate first; flush the toilet; and then defecate in the toilet, a bedpan (preferably one that is
placed on the toilet to avoid embarrassment), or a commercial potty hat.
Stool specimens should be large enough to obtain an ample sampling, not merely a fecal
fragment. Specimens are placed in an appropriate container, which is covered and labeled. If
several specimens are needed, the containers are marked with the date and time and kept in a
specimen refrigerator. Special care is exercised in handling the specimen because of the risk
of contamination.
272. Pediatrics-Gwth & Devlp/Physical Assessment-Child interview-school age
Child 9 years old:
a. Talk directly to the child
b. Ask the child if the parents are saying the true
c. Tell the parents to get out of the room
Answer: a. Talk directly to the child
273. Pediatrics-Immune/Hematology- von Willebrand’s disease-POC (Bleeding disorder)
a. Decrease exposure to infection
b. Decrease contact with other children
c. Decrease contact with cold graft
d. Guard against bleeding injuries
Answer: d. Guard against bleeding injuries
274. Pediatrics-Integumentary-Burns-hydrotherapy
Answer: Let the child touch the water
275. Pediatrics-Musculoskeletal- Congenital hip-1st action 2 days old infant legs flexed with
limited abduction, what is the next action that the nurse take:
a. Range of motion exercise
b. Notify MD
c. Document as an normal finding

d. Continue with the care
Answer: b. Notify MD
276. Pediatrics-Neurological-Vegetative state-adolescent
Un Nino en estado vegetative hace 5 meses. RN q hacer
Answer: Talk to the child
277. Pediatrics- Renal-Nephrotic syndrome-I&O
2 year old child with nephrotic syndrome taking corticosteroids is edematous and fatigue.
What action the nurse implement first.
a. Sign and symptom of Cushing
b. Restrict sodium
c. Intake and output
d. Measure abdominal girth for 2 days
Answer: c. Intake and output
278. Pediatrics-Respiratory-Cystic fibrosis-med
The nurse is evaluating the home care teaching of a family who has a child with cystic
fibrosis. Which parental action indicates correct understanding of the child’s home care?
a. Performs postural drainage after meals
b. Supplements diet with water-soluble vitamins and fluids
c. Plans a diet high in fat and calories
d. Gives pancreatic enzymes before every meal and snack
Answer: d. Gives pancreatic enzymes before every meal and snack
279. Pediatrics-Respiratory-RSV-isolation
Answer: Contact precautions
280. Pediatrics/Medical Surgical-Respiratory-Theophylline-toxicity PEDI
A 4-YEAR-OLD child hospitalized with asthma is receiving theophylline. Which observation
by the nurse warrants immediate intervention?
a. The child heart rate is 110.
b. The child’s breath sounds indicate bilateral expiratory wheezing.
c. The child is sitting straight up in bed. irritable.

d. The child is nauseated and
Answer: d. The child is nauseated and
281. Professional Issues-Cultural/Spiritual/Leadership/Legal/Ethical-Post mortum care
Patient dies and family want to see him before the home funeral arrived, the nurse should
enter first to the room (select all that apply):
a. Remove The Resuscitation Equipment
b. Remove the dentures
c. Close his eyes
d. Put A Pillow Under The Head
e. Use A Shroud Bag
Answer: a. Remove The Resuscitation Equipment
c. Close his eyes
282. Professional Issues-Documentation/Leadership/Legal/Ethical-Team managementdocumentation
When the nurse manager and the nursing staff review entries into the electronic medical
records (EMR), they determine that procrastination is often the reason for late-entries. What
recommendation should the nurse manager offer to the nursing staff?
a. Document routine care as provided and complex care at the end of shift
b. Enter tasks in the EMR as the client's priority needs are addressed
c. Document nursing care procedures between time-dependent cares
d. Keeps notes and enter all documentation at the end of the shift
Answer: b. Enter tasks in the EMR as the client's priority needs are addressed
283. Professional Issues-Leadership-Conflict resolution-arguing staff
Two unlicensed assistive personal (UAP) are arguing loudly in the hallway of an extended
care facility about who will shower a male resident who defecated in his bed. What action is
best for the charge nurse to take?
a. Instruct both UAPs are to shower the client immediately.
b. Shower the client with the help of a practical nurse.
c. Document the conflict in the employee personnel files.
d. Reassign the client’s care to another staff member.
Answer: a. Instruct both UAPs are to shower the client immediately.

284. Professional Issues-Leadership/Legal/Ethical-Decision to strike
Nursing strike bargaining:
a. Nurses should prioritize their personal interests over patient care.
b. Nurses should continue working without expressing concerns during the bargaining
process.
c. Nurses should advocate for better working conditions and patient safety during
negotiations.
d. Nurses should support the employer’s stance without engaging in negotiations.
Answer: d. Nurses should support the employer’s stance without engaging in negotiations.
285. Professional Issues-Leadership/Legal/Ethical-Delegate-follow- up
As team leader, the nurse is caring for a group of clients with the help of a practical nurse
(PN) and experienced unlicensed assistive personnel (UAP). Which nursing actions should
the nurse assign to the PN? (Select all that apply)
a. Change surgical dressing daily for a client who had an abdominal hysterectomy
b. Obtain postoperative vital signs for a client with an epidural analgesic after having a knee
arthroplasty
c. Start a blood transfusion for client who just returned to the room following a below knee
amputation
d. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus
(DM)
Answer: a. Change surgical dressing daily for a client who had an abdominal hysterectomy
b. Obtain postoperative vital signs for a client with an epidural analgesic after having a knee
arthroplasty
d. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus
(DM)
286. Professional Issues-Leadership/Legal/Ethical-Prescription-poorly written
The unit clerk reports to the charge nurse that a healthcare provider has written several
prescriptions that are eligible and it appears the healthcare provider used several
abbreviations in the prescription. What action should the charge nurse take?
a. Report the situation to the house supervisor
b. Complete and incident (variance) report

c. Call the healthcare provider who wrote the prescriptions
d. Contact the healthcare provider review board for instructions
Answer: c. Call the healthcare provider who wrote the prescriptions
287. Professional Issues-Leadership/Legal/Ethical-Sexual harassment
a. "I know you are a good nurse and can handle this client."
b. "If you feel uncomfortable, we can address this issue through the proper channels."
c. "Please report any incidents of harassment to HR so that we can take appropriate action."
d. "I will support you in any way I can to ensure your safety and comfort."
Answer: a. "I know you are a good nurse and can handle this client."
288. Professional Issues-Leadership/Legal/Ethical-UAP assign-escort client
Answer: Transfer the patient in the wheelchair to another room
289. Professional Issues-Leadership/Legal/Ethical/Nursing Process-Advocate
a. Ensure that the client receives their prescribed medications on time.
b. Encourage the client to express their concerns and preferences in care decisions.
c. Collect data to assess the client's medical history and current condition.
d. Administer treatments and follow prescribed interventions accurately.
Answer: b. Encourage the client to express their concerns and preferences in care decisions.
290. Professional Issues/Medical Surgical-Documentation-Heart sounds- murmur
SOUND
a. Murmur
b.S1, S2
c. S1, S2, S3
d. Peripheral
Answer: a. Murmur
291. Professional Issues/Medical Surgical-Legal/Ethical-Forensic nursing clothing
A young adult male is brought to the emergency room with a multiple gunshot wounds in the
chest abdomen, and head. After collecting the client’s blood- saturated clothing as forensic
evidence or the medical examiner, which action should the nurse implement?
a. Drop the clothes in a plastic bag and seal the bag with transported tape.

b. Place clothing in a large specimen container and send to the pathology lab.
c. Place the folded clothes in a paper bag transfers it to red biohazard bag.
d. Roll the clothing in a towel and cover it with an impermeable drape.
Answer: c. Place the folded clothes in a paper bag transfers it to red biohazard bag.
292. Professional Issues/Medical Surgical-Legal/Ethical-SBAR-call HCP- femoral stent
Abdominal left femoral angioplasty:
a. Surgeon Needs To See
b. Left Pheripheral Pulses
c. Right Pheripheral Pulses
Answer: b. Left Pheripheral Pulses
293. Professional Issues/Medical Surgical-Teaching-Dronedarone-client instructions
Dronedarone medication and the pt take grapefruit what we need to teach indiet.
a. Discontinue grapefruit immediately.
b. Avoid grapefruit while taking dronedarone.
c. Notify the healthcare provider if grapefruit is consumed.
Answer: b. Avoid grapefruit while taking dronedarone.
294. Professional Issues/Medical Surgical-Teaching-Orchiectomy-wound care
Testiculo remove: asw: …..Support
Answer: Support
295. Psychiatric/Mental Health-Abuse-CAGE scoring
The questionnaire asks the following questions
• Have you ever felt you needed to Cut down on your drinking?
• Have people Annoyed you by criticizing your drinking?
• Have you ever felt Guilty about drinking?
• Have you ever felt you needed a drink first thing in the morning (Eyeopener) to steady your
nerves or to get rid of a hangover?
The CAGE questionnaire, among other methods, has been extensively validated for use in
identifying alcoholism. CAGE is considered a validated screening technique, with one study
determining that CAGE test scores >=2 had a specificity of 76% and a sensitivity of 93% for

the identification of excessive drinking and a specificity of 77% and a sensitivity of 91% for
the identification of alcoholism.
The nurse is with a patient doing a CAGE questionary 3 positive response. What the nurse
….
a. Is a questionary for substance abuse
b. 1 positive seek help for alcohol dependence
c. Al least 2 positive strongly alcohol dependence
d. All positive suggest alcohol dependence
Answer: c. Al least 2 positive strongly alcohol dependence
296. Psychiatric/Mental Health-Anxiety/Communications-Communication-caregiver support
The home care nurse go to visit a patient with Alzheimer’s and find the wife crying, what
happen with your husband and the wife respond “watch it with your own eyes”. What action
should the nurse…..
a. Encourage wife to leave home
b. Ask the wife to observe the assessment to learn how to take deal with the situation
c. As soon as the client care is completed provide wife with family support group
d. Sit with the wife and talk about her concerns
Answer: d. Sit with the wife and talk about her concerns
297. Psychiatric/Mental Health-Anxiety/Communications-PTSD-maladaptive behavior
Adult male witnessed the murder:
a. “It’s better than killing someone”
b. “Tell Me More About The Murderyou Recently Witnessed”
c. “You Feel Guilty Forthe Murder”
Answer: b. “Tell Me More About The Murderyou Recently Witnessed”
298. Psychiatric/Mental Health-Anxiety/Communications/Psychoses-Manic acting out
A group of students along with the nurse are on a tour of the hospital in the area of psychiatry
and while they were down the hall one patient says "want to see a crazy patient” and start to
jump and scream and make hands like a chicken . What should the nurse do?
a. Ignore the patient and continue with a tour
b. Give PRN anxiety medication
c. Call the security

d. shake it and bring it to normal state
Answer: a. Ignore the patient and continue with a tour
299. Psychiatric/Mental Health/Fundamentals-Abuse/Basic Nursing Skills/Mobility/SafetyRestrains-physical harm Chequiar la circulation en la restrains or reposition the restrains
Answer: Chequiar la circulation en la restrains or reposition the restrains
300. Psychiatric/Mental Hlth/Fundamentals-Abuse/Basic Nursing Skills/Nutrition-Bulimiamaintain weight
Answer: Scheduled meal and snack
Bulimia nervosa is an eating disorder characterized by binge eating and purging, or
consuming a large amount of food in a short amount of time followed by an attempt to rid
oneself of the food consumed (purging), typically by vomiting, taking a laxative, diuretic, or
stimulant, and/or excessive exercise, because of an extensive concern for body weight.
301. Psychiatric/Mental Health/Fundamentals-Anxiety/Communications/Basic Nursing
Skills/Safety-Aggression-triggering
A client who has a history of aggressive and hostile behavior is in the triggering phase of the
aggression cycle. Which action should the nurse implement first?
a. Encourage the client to verbalize angry feeling.
b. Obtain staff assistance to confront the client.
c. Administer a PRN medication to the client
d. Physically escort the client to a quiet cooling off area.
Answer: a. Encourage the client to verbalize angry feeling.
302. Psychiatric/Mental Health/Fundamentals/Maternity/Professional IssuesDepress/Grief/Basic Nursing Skills/Nutrition/Postpartum/Nursing Process-PP depressiongoals-POC
Una pt con postpartun y dejo de comer y perdio peso . Short
Goal
Answer: 100ml and 3 food
303. Psychiatric/Mental Health/Fundamentals/Medical Surgical-Psychoses/Basic Nursing
Skill/Safety-Priority-Endocrine Unit

A male client, who had a total laryngectomy two days ago, is transferred from the intensive
care unit to a private room close to the nurse’s station. The nurse recognizes that the client is
anxious. Which intervention should the nurse implement?
a. Encourage a family member to stay with the client at all times
b. Answer the client’s call signal in person quickly after the calls
c. Explain the emergency procedure for loss of airway to the client
d. Provide the client with a suction catheter to allow for self-suctioning
Answer: b. Answer the client’s call signal in person quickly after the calls
304. Psychiatric/Mental Health/Geriatrics/Medical Surgical-Anxiety/CommunicationsColostomy-postop confusion . Psychiatric/Mental Health/Maternity-Abuse/NewbornNeonate-cocaine-withdrawal
A neonate whose mother used cocaine during pregnancy is demonstrating excessive shrill cry,
and frequent vomiting. What action should the nurse perform first?
a. Request a neurology assessment.
b. Wrap the infant in warm blankets.
c. Obtain a serum screen.
d. Burp the infant to eliminate gas.
Answer: c. Obtain a serum screen.
305. Psychiatric/Mental
Health/Maternity/Anxiety/Communications/Intrapartum-Angry family member
The patient was in pain and mom was saying she was ready for cesarean because she knew
what had already had 8 children.
a. Call the security
b. Ask her to leave the room
c. Call the charge nurse
Answer: b. Ask her to leave the room
306. Psychiatric/Mental Health /Medical Surgical-Hip fracture
Anxiety/CommunicationsAn elderly patient who lives alone and falls, hip fractures and goes to hospital. She was
worried about her dog. (Select all that apply):
a- Put 2 pillows

b. PRN med
c. Contact social worker
d. Ignore the patient
Answer: a- Put 2 pillows
b. PRN med
c. Contact social worker
307. Psychiatric/Mental Health/Pathophysiology/Medical Surgical-Abuse-Hepatic
encephalopathy ( ammonia level alto)
A male client with a long history of alcoholism is admitted because of mild confusion and fir
motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one
month ago after his brother died of lung cancer. Which intervention is most important for the
nurse to include in the client’s plan of care?
a. Observe for changes in level of consciousness
b. Provide grief counseling for client and his family
c. Involve the client’s family in healthcare decision
d. Determine client’s current blood alcohol level.
Answer: a. Observe for changes in level of consciousness
308. Psychiatric/Mental Health/Pediatrics-Depress/Grief-Grief-adolescent
The child at school said that had a lot of headache and go to the nurse. What comment made
by the child concerned the nurse?
Answer: The child says something that wants to see his mom
309. Psychiatric/Mental Health/Professional IssuesAnxiety/Communications/Leadership/Legal/Ethical-EOL care-fear
Patient in hospice care at home fear dying will be painful….
a. Encourage to talk about
b. Explain that pill will be given
c. Provide therapeutic touch with comfort and support
Answer: c. Provide therapeutic touch with comfort and support
310. Psychiatric/Mental Health/Professional IssuesAnxiety/Communications/Leadership/Legal/Ethical-Med error-communication

2 nurse discutiendo en el pasillo es el pt escucho que le dieron med mal. Q hacer?
Answer: apologies with the pt
311. Psychiatric/Mental Health/Professional Issues-Depress/Grief/Nursing ProcessDepression-nursing problem
Answer: For a patient experiencing depression and grief, the nursing problem could be:
Impaired coping related to overwhelming sadness and loss. Risk for self-harm related to
feelings of hopelessness and low self-esteem.
312. Psychiatric/Mental Health/Professional Issues-Psychoses/Documentation/Nursing
Process-Delusions-POC
Answer: Deliria/delusions
Delusions are beliefs that guide one's interpretation of events and help make sense out of
disorder. The delusions may be comforting or threatening, but they always form a structure
for understanding situations that otherwise might seem unmanageable. A delusional disorder
is one in which conceivable ideas, without foundation in fact, persist for more than 1 month.
These beliefs are not always bizarre and do not originate in psychotic processes. Common
delusions are of being poisoned, being followed, their children taking their assets, being held
prisoner, or being deceived by a spouse or lover.
One older woman persistently held onto the delusion that her son was coming to pick her up
and take her home, although her son had been dead for 10 years.
313. Psychiatric/Mental Health/Professional Issues-Medical
Abuse/Anxiety/Communications/Legal/Ethical-Date rape-Surgical-denial
The patient from college that was drinking last night with friends. Go to the hospital
a. I’m sorry to hear this
b. You remembered if someone put something in the drink or if she remember what she drink
c. You know the people who did this
d. You feel guilty about what happened to you
Answer: b. You remembered if someone put something in the drink or if she remember what
she drink
314. Psychiatric/Mental Health/Professional Issues-Medical Surgical Anxiety/Communications/Depress/Grief/Leadership-Liver transplant-anger

The RN sends the UAP to the room to do care to the patient but the patient was anger and
yelling to the UAP. What can the UAP do?
a. Schedule the care daily
b. Not enter more in the room
c. Give care earlier
d. Give care options participate
Answer: d. Give care options participate

EXTRA QUESTIONS:
315. A patient with cystic fibrosis is …… human deoxyribonuclease. What finding require
the nurse intervention?
a. Increase mucuos thinned
b. Increase 2 pounds
c. Decrease frequency steatorrhea
Answer: a. Increase mucuos thinned
316. Large blister (back) chest soaked serosanguinious during assessment. What finding
requires immediate intervention?
a. Headache
b. Fever/Chills
c. Decrease Blood Pressure
d. Dizzness
Answer: b. Fever/Chills
317. Two RNs were arguing over a medication, and the patient overheard. What is the first
thing the charge nurse should do?
a. Charge nurse apologizes to the patient
b. Look for documentation
c. Meet with the two nurses and review the patient's privacy and the hospital's policy
Answer: c. Meet with the two nurses and review the patient's privacy and the hospital's
policy

Hesi med surge review Package of Pictures
318. What instruction should the nurse include in the discharge teaching plan of a client who
had a cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avoid heavy lifting
c. Use a metal eye shield on operative eye during the day
d. Administer eye ointment before applying eye drops
Answer: b. Light housekeeping is permitted but avoid heavy lifting
319. A male adult comes to the urgent care clinic 5 days after being diagnose with influenza.
He is short of breath, febrile, and coughing green colored sputum. Which intervention should
the nurse implement first?
a. Obtain a sputum sample for culture
b. Check his oxygen saturation level
c. Administer an oral antipyretic
d. Auscultate bilateral lung sound
Answer: a. Obtain a sputum sample for culture
320. An elder male client tells the nurse that he is loosing sleep because he has to get up
several times at night to go to the bathroom that he has trouble starting his urinary stream and
that he does not feel like his bladder is ever completely empty. Which intervention should the
nurse implement?
a. collect a urine specimen for culture analysis
b. obtain a fingerstick blood glucose level
c. palpate the bladder above the symphysis pubis
d. review the client fluid intake
Answer: c. palpate the bladder above the symphysis pubis
321. An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract
infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated.
Which serum laboratory value warrants the most immediate intervention by the nurse?
a. blood ph of 7.30

b. glucose of 350 mg /dl
c. white blood cell count of 15000mm
d. potassium of 2.5 meq/l
Answer: d. potassium of 2.5 meq/l
322. A client with sickle cell anemia develops a fever during the last hour of administration of
a unit of packed red blood cell. When notifying the healthcare provider what information
should the nurse provide first using the SBAR communication process?
a. explain specific reason for urgent notification
b. preface the report by stating the clients name and admitting diagnosis
c. communicate the pre-transfusion temperatures
d. optain prn prescription for acetaminophen for fever 101f
Answer: a. explain specific reason for urgent notification
323. An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to
aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this
client for discharge what important aspect regarding his medication therapy should the nurse
explain?
a. AZT therapy must be stopped when IV aerosol pentamine is being used.
b. IV pentamine will be given until oral pentamine can be tolerated
c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month
d. Iv pentamine may offer protection to others aids related conditions such as kaposis
sarcoma
Answer: c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine
every month
324. A client subjective data includes dysuria, urgency, and urinary frequency. What action
should the nurse implement next?
a. collect a clean catch specimen
b. palpate the suprapubic region
c. instruct to wipe from front to back
d. inquire about recent sexual activity
Answer: a. collect a clean catch specimen

325. A client tells the nurse that her biopsy results indicate that the cancer cells are well
differentiated How should the nurse respond?
a. offer the client reassurance that this information indicates that the clients cancer cells are
benign
b. explain that these tissue cells often respond more effectively to radiation than to
chemotherapy
c. ask the client in the healthcare provider has giving her any information about the
classification of her cancer
d. help the client make plans to begin immediate treatment since her cancer is likely to spread
quickly
Answer: c. ask the client in the healthcare provider has giving her any information about the
classification of her cancer
326. A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment
clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first?
a. monitor bp q45 minutes
b. lower the head of the chair and elevate feet
c. stop dialysis treatment
d. administer 5%albumin IV
Answer: c. stop dialysis treatment
327. A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin
sodium 25, 000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage
should be increase 900 units/hr. The nurse should program the infusion pump to deliver how
many ml/hr?
a. 9
b. 8
c. 7
d. 6
Answer: a. 9
328. The nurse is obtaining the admission history for a client with suspected peptic ulcer
disease (PUD). Which subjective data reported by the client supports this diagnosis?
a. upper mid abdominal gnawing and burning pain

b. severe abdominal cramps and diarrhea after eating spicy foods
c. marked loss of weight and appetite over the last few months
d. use of chewable and liquid antacids for indigestion
Answer: a. upper mid abdominal gnawing and burning pain
329. The nurse is providing preoperative education for a jewish client schedule to receive a
xenograft graft to promote burn healing. Which information should the nurse provide this
client?
a. the xenograft is taken from nonhuman sources
b. grafting increases the risk for bacterial infection
c.as the burn heals the graft permanently attaches
d. grafts are later removed by debriding procedure
Answer: a. the xenograft is taken from nonhuman sources
330. A client who took a camping vacation two weeks ago in a country with a tropical climate
comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding
is most important for the nurse to report?
a. jaundice sclera
b. intestinal cramping
c. weakness and fatigue
d. weight loss
Answer: a. jaundice sclera
331. During a home visit the nurse assesses the skin of a client with eczema who reports than
an exacerbation of symptoms has occurred during the last week. Which information is most
useful in determining the possible cause of the symptoms?
a. an old friend with eczema came for visit
b. recently received an influenza immunization
c. corticosteroid cream was applied to eczema
d. a grandson and his new dog recently visited
Answer: d. a grandson and his new dog recently visited
332. When explaining dietary guidelines to a client with acute glomerulonephritis (AGN)
which instruction should the nurse include in the dietary teaching ?

a. select a protein rich food daily
b. restrict sodium intake
c. eat high potassium foods
d. Avoid foods high in carbohydrate
Answer: b. restrict sodium intake
333. A male client who is 24hr post operative for an exploratory laparoctomy complains that
he is starving because he has had no real food since before surgery. Prior to advancing his
diet which intervention should the nurse implememt?
a. discontinue intravenous therapy
b. Assess for abdominal distension and tenderness
c. Obtain a prescription for a diet change
d. Auscultate bowel sound in all four quadrants
Answer: d. Auscultate bowel sound in all four quadrants
334. A client diagnose with stable angina secondary to ischemic heart disease has a
prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to
follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart?
a. drive to the nearest emergency department
b. take another NTG SL tablet and lie down until angina subsides
c. call primary healthcare provider
d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg
Answer: d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg
335. After taking orlistat (Xenical) for one week a femela client tells the home health nurse
that she is experiencing increasingly frequent oily stools and flatus. What action should the
nurse take?
a. obtain stool specimen to evaluate for occult blood and fat content
b. instruct the client to increase her intake of saturated fats over the next week
c. ask the client to describe her dietary intake history for the last several days
d. advice the client to stop taking the drug and contact the healthcare provider
Answer: c. ask the client to describe her dietary intake history for the last several days

336. Two days after an abscess of the chin was drained the client returns to the clinic with
fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and
cleansed the wound today with provide iodine (Betadine) solution. Which intervention should
the nurse implement first?
a. determine if the client has a history of diabetes
b. assess airway patency and oxygen saturation
c. review recent medication history and allergies
d. obtain samples for complete blood count and cultures
Answer: b. assess airway patency and oxygen saturation
337. A client experiences an ABO incompatibility reaction after multiple blood transfusions.
Which finding should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
Answer: a. low back pain and hypotension
338. A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the
intensive care unit with hyperglycemic nonketotic symdrome (HHNS). A sliding scale
protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a
continuous blood glucose monitoring device that is attached to the clients central venous
catheter. When the clients respirations become labored and his lungs sound indicate crackles
what action should the nurse take?
a. collect a specimen for a white blood cell count and cultures
b. determine the clients glycosylated hemoglobin (A1C)
c. administer insulin IV push until the clients fluid volume is adjusted
d. decrease infusion rate to address fluid overload
Answer: d. decrease infusion rate to address fluid overload
339. When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that
the previously applied patch is intact on the clients upper back and the client denies pain.
What action should the nurse take?
a. Remove the patch and consult with the healthcare provider about the client pain resolution

b. Place the patch on the clients shoulder and leave both patches in place for 12 hours
c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch
d. Apply a new patch in a different location after removing the original patch
Answer: d. Apply a new patch in a different location after removing the original patch
340. A client who had a myocardial infarction is admitted to the coronary critical care unit
(CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was
78/36.What action should the nurse implement?
a. obtain blood pressure q5 minutes using duranap machine
b. change the dilution of the nytroglycerin infusion
c. reduce the rate of the nitroglycerin infusion
d. begin dopamine infusion at 5mcg/kg per minute
Answer: c. reduce the rate of the nitroglycerin infusion
341. An adolescent is admitted to the hospital because of a suicide attempt with an overdose
of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor
during the first 72 hours following ingestion of this overdose?
a. BUN creatinine specific gravity
b. White blood count, hemoglobin hematocrit
c. PH, PCO2, HCO3
d. LDH OR LD, SGOT OR ALT, SGPT OR AST.
Answer: d. LDH OR LD, SGOT OR ALT, SGPT OR AST.
342. An elderly post operative female client is receiving morphine sulfate via a PCA pump.
Which assessment finding should prompt a nurse to administer the prescribed PRN
medication naloxone?
a. her respiratory rate is 7 breath/minute
b. she indicates that she feels as if she cannot get enough air to breath
c. she has intercostal retractions and bilateral wheezing is auscultated
d. her pulse oximeter is 89% on room air
Answer: a. her respiratory rate is 7 breath/minute
343. Which assessment finding indicates to the nurse that the muscarinic agent bethanechol
(Urecholine) is effective for a client diagnose with urinary retention?

a. urinary output equal to intake
b. no terminal urinary dribbling
c. denies stress incontinence
d. absence of xerostomia
Answer: a. urinary output equal to intake
344. Following involvement in a motor vehicle collision, a middle aged adult client is
admitted to the hospital with multiple facial fractures. The clients blood alcohol level is high
on admission. Which PRN prescription should be administer if the clients begins to exhibit
signs and symptoms of delirium tremens (DT s)?
a. Lorazepam (Ativan) 2mg IM
b. Chlorpromazine (thorazine) 50 mg IM
c. Prochlorperazine (Compazine) 5 mg IM
d. Hydromorphone (Dilaudid) 2 mg IM
Answer: a. Lorazepam (Ativan) 2mg IM
345. Which instructions should the nurse include in the teaching plan of a client who is taking
the diuretic spironolactone (Aldactone)?
a. call the healthcare provider f you develop gynecomastia
b. Take the medication in the morning
c. Avoid caffeine and smoking
d. Increase your consumption of bananas and oranges
Answer: b. Take the medication in the morning
346. A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When
should the nurse instruct the client to take the glucagon?
a. after meals to increase endogenous insulin secretion
b. after insulin administration to prevent hypoglycemia
c. when recognized signs of severe hypoglycemia occur
d. when unable to eat during sick days
Answer: c. when recognized signs of severe hypoglycemia occur
347. A client with hyperthyroidism is being treated with radioactive iodine (I-131).
Which explanation should be included in preparing this client for this treatment?

a. describe radioactive iodine as a tasteless, colorless medication administered by the
healthcare provider
b. explain the need for using lead shields for 2 to 3 weeks after the treatment
c. describe the signs of goiter because this is a common side effects of radioactive iodine
d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately
Answer: a. describe radioactive iodine as a tasteless, colorless medication administered by
the healthcare provider
348. A female client is being treated for tuberculosis with rifampin (rifadin) Which statement
indicates that futher teaching is needed?
a. "I will take my usual contraceptive for birth control."
b. "I will take the medication exactly as prescribed and finish the entire course."
c. "I will report any unusual fatigue or yellowing of my skin."
d. "I will wear protective clothing and sunscreen when going outside."
Answer: a. "I will take my usual contraceptive for birth control."
349. A client is discharged with a prescription for warfarin ( Coumadin). What discharge
instructions should the nurse emphasize to the client?
a. take a multi vitamin supplement daily
b. use an astringent for superficial bleeding
c. avoid going barefoot especially outside
d. include large amounts of spinach in the diet
Answer: c. avoid going barefoot especially outside
350. In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone
intranasally which serum lab test is most important for the nurse to monitor?
a. osmolality
b. calcium
c. platelets
d. glucose
Answer: a. osmolality

351. After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with
a severe migraine headache the nurse should explain that relief can be expected within what
time frame?
a. 2 hours
b. 5 minutes
c. 1 hour
d. 15 minutes
Answer: d. 15 minutes
352. A client with hypertension who has been taking labetalol for two weeks, reports a five
pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to
obtain?
a. capillary refill
b. body temperature
c. muscle strength
d. breath sounds
Answer: d. breath sounds
353. A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops
for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What
explanation should the nurse provide?
a. The eye drops slow pupil response to accommodate for darkness
b. The drops increase the fluid in the eyes and cloud the visual field
c. The drug can cause lens to become more opaque
d. The medication causes pupils to dilate which reduces night vision
Answer: a. The eye drops slow pupil response to accommodate for darkness
354. A client who is taking and oral dose of tetracycline complains of gastrointestinal upset.
What snack should the nurse instruct the client to take with the tetracycline?
a. toasted wheat bread and jelly
b. cheese and crakers
c. cold cereal with skim milk
d. fruit flavored yogurt
Answer: a. toasted wheat bread and jelly

355. The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which
physiologic action?
a. Facilitates transport of glucose into the cell
b. Increases intracellular receptor site sensitivity
c. Stimulates function of beta cells in the pancreas
d. Delays carbohydrates digestion and absorption
Answer: a. Facilitates transport of glucose into the cell
356. The health care provider prescribe a medication for an older adult client who is
complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should
question which prescription?
a. Eszoplicone (Lunesta)10 mg orally at bed time
b. Zolpidem 10 mg orally at bed time
c. Temazepan orally at bed time
d. Ramelteon orally at bedtime
Answer: a. Eszoplicone (Lunesta)10 mg orally at bed time
357. A male client reports to the nurse that he is experiencing GI distress from high dose of a
corticosteroid and is planning to stop taking the medication. In response to the clients
statement what nursing action is most important for the nurse to take?
a. Encourage the client to take medication with food to decrease GI distress
b. Advice the client that the medication should be stopped gradually rather than abruptly.
c. Review the clients dosing schedule to ensure he is taking the prescribed amount
d. Assess the client for other indication of adverse effects of corticosteroid
Answer: b. Advice the client that the medication should be stopped gradually rather than
abruptly.
358. Fifteen minutes after receiving sulfa athenozole . A male client report a burning
sensation over his abdomen chest and groin. Which intervention is most important for the
nurse to implement?
a. Auscultate lung sounds for wheezing
b. Review the clients list if drugs allergies
c. Add sulfamethinozole to clients allergies

d. Check neurological vital signs
Answer: b. Review the clients list if drugs allergies
359. Antibiotic resistant organism are a major infection control problems. To help minimize
the emergence of resistant bacteria what instruction should the nurse provide to the clients?
a. stop taking prescribed antibiotics when symptoms decrease
b. avoid using antibiotics when suffering from colds or the flu
c. ask the healthcare provider to prescribe the newest antibiotic when needed
d. request a prescription for first time vancomysin for a sore throat
Answer: b. avoid using antibiotics when suffering from colds or the flu
360. A client with symptoms of influenza that started the previous day ask the clinic nurse
about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse
provide?
a. Advise the client once symptoms occur is too late to receive an influenza vaccination
b. Refer the client to the healthcare provider at the clinic to obtain a medication prescription
c. Explain to the client that antibiotics are not useful in treating viral infections such as
influenza
d. Instruct the client that over the counter medications are sufficient to manage influenza
symptoms
Answer: b. Refer the client to the healthcare provider at the clinic to obtain a medication
prescription
361. Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2
grams using an infusion pump to deliver the dose in one hour, the client reports feeling
nauseated. What action should the nurse implement?
a. stop medication infusion and notify the healthcare provider of the adverse effect
b. increase the rate of the infusion to complete the dose of the medication more rapidly
c. continue the infusion and administer a prn antiemetic prescription
d. reasurre the client that the nausea is not related to the iv infusion
Answer: c. continue the infusion and administer a prn antiemetic prescription
362. The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimers
disease as an intervention for which client problem?

a. fluid volume excess
b. disturbed though processes
c. chronic pain
d. altered breathing patterns
Answer: b. disturbed though processes
363. To prevent deep vein thrombosis following knee replacement surgery, an adult male
client is receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding
requires immediate action by the nurse?
a. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI)
b. Hematocrit 45%
c. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI)
d. Platelet count of 100, 000/mm3 or 100x109/ L (SI)
Answer: d. Platelet count of 100, 000/mm3 or 100 x 109/ L (SI)
364. A client with type 2 diabetes mellitus is managed with metformin (Glucophage), an oral
hypoglycemic agent. The primary health care provider prescribes ad additional medication
injected exenatide (byetta). Which information is most important for the nurse to teach this
client?
a. Administer subcutaneously after meals
b. Consume additional sources of potassium
c. Notify the healthcare provider if anorexia occurs
d. Watch for signs of jitteriness or diaphoresis
Answer: b. Consume additional sources of potassium
365. A client is who is diagnose with schizophrenia receives a prescription for a atypical
antipsychotic drug aripipazole (Abilify). Which assessment should the nurse perform to
monitor for an adrenergic receptor antagonist side effect that commonly occurs atypical
antipsychotic agents?
a. observe the client hallucinatory behaviors
b. obtain the client fingerstick glucose levels
c. measure the clients lying and standing blood pressure
d. determine the clients abnormal involuntary movements scale (AIMS)
Answer: b. obtain the client fingerstick glucose levels

**Packete que empieza con HES I MED SURGE 2 Y
HESSI RETAKE AQUI
ESTA RESUMIDO SIN COSAS REPETIDAS
366. A client with pheocromocytoma reports the onset of a severe headache.
The nurse observes that the client is very diaphoretic. Which assessment data should the
nurse obtain first.
Answer: Blood pressure
367. The drainage in the chest tube of a client with emphysema has changed from clear
watery fluid. What action would be best for the nurse to take/
Answer: Maintain the current IV antibiotic schedule
368. A client is admitted with a sudden onset of right sided the nurse complete first?
Answer: Observe for peripheral edema
369. When planning care for a client newly diagnose with open angle glaucoma, the nurse
identifies a priority nursing diagnosis of “ Visual sensory/perceptual alterations”. This
diagnosis is based on which etiology?
Answer: Decreased peripheral vision
370. A client in the operating room received succinylcholine. The client is experiencing
muscle rigidity and has an extremely high temperature. What action should the nurse
implement?
Answer: • Call the PACU nurse to prepare for prolonged ventilatory support
• Also know that PACU is BP, Respiration and Pulse
371. A client who is receiving packed red blood cells develops nausea and vomiting. What
action should the nurse take first?
Answer: • Stop the infusion of blood
• Te lo pueden poner como hemodialysis y tambien es STOP transfusion

372. A client with type 2 diabetes mellitus is admitted to the hospital for uncontrolled DM.
Insulin therapy is initiated with initial dose of Humulin insulin at 8:00 at 16:00 the client
complains of diaphoresis, rapid heart beat, and feeling shaky. What should the nurse do first?
Answer: Determine the client current glucose level
373. After suctioning the patient with an endotracheal tube, which assessment finding
indicates to the nurse that the intervention was effective?
Answer: Increase in breath sounds
374. The nurse observes an increase number of blood clots in the drainage tubing of a client
with continuous bladder irrigation following a transurethral resection of the prostate (TURP).
What is the best initial nursing action?
Answer: • Provide additional oral fluid intake
• Also with TURP you must know that 3l of water a day is needed
375. Which nursing diagnosis should be selected for a client who is receiving thrombolytic
infusions for treatment of an acute myocardial infarction?
Answer: Risk for injury related to effects of thrombolysis
376. The nurse is assessing a client who has returned from surgery following a thoracotomy.
Which finding indicates the client is experiencing adequate gas exchange?
Answer: The client demonstrates effective coughing and deep breathing exercises
377. When caring for a client with nephrotic syndrome which assessment is most important
for the nurse to obtain?
Answer: Daily Weight
378. A client who had a biliopancreatic diversion procedure (BOP) 3 months ago is admitted
with severe dehydration. Which assessment finding warrants immediate intervention by the
nurse?
Answer: Gastroccult positive emesis

379. A female client with possible acute renal failure (ARF) is admitted to the hospital and
mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out this prescription,
what intervention should the nurse implement?
a. No specific nursing action is required
b. Instruct the client to empty the bladder
c. Collect a clean catch urine specimen
d. Obtain vital signs and breath sounds
Answer: d. Obtain vital signs and breath sounds
380. The nurse positions a male client for a lumbar puncture by placing him in the side- lying
position with his knees flexed and pulled toward his trunk. What action should the nurse
implement next?
a. Call another nurse to assist the healthcare provider
b. Provide a small pillow for the client to curl around
c. Instruct the client to perform a Valsalva maneuver
d. Support the client’s head bent forward to the chest
Answer: d. Support the client’s head bent forward to the chest
381. When teaching a client with osteoporosis to increase weight-bearing exercise, how
should the nurse explain the purpose of this activity?
a. Strengthen leg muscles
b. Promote venous return
c. Increase bone strength
d. Restore range of motion
Answer: c. Increase bone strength
382. A male tells the clinic nurse that he is experiencing burning on urination, and assessment
that he had sexual intercourse four days ago with a woman he casually met. Which action
should the nurse implement?
a. Observe the perineal area for a chancroid-like lesion
b. Obtain a specimen of urethral drainage for culture
c. Identify all sexual partners in the last four days
d. Assess for perineal itching, erythemia, and excoriation
Answer: d. Assess for perineal itching, erythemia, and excoriation

383. An older female client with long term type 2 diabetes mellitus (DM) is seen in the doctor
routine health assessment. To determine if the client is experiencing any longterm
complications of DM, which assessments should the nurse obtain? Select all that apply:
a. Visual acuity
b. Serum creatinine and blood urea nitrogen (BUN)
c. Signs of respiratory tract infection
d. Sensation in feet and legs
e. Skin condition of lower extremities
Answer: a. Visual acuity
b. Serum creatinine and blood urea nitrogen (BUN)
d. Sensation in feet and legs
e. Skin condition of lower extremities
384. Which laboratory test result is most important for the nurse to report to the surgeon prior
to a client’s scheduled abdominal surgery?
a. Potassium level of 4 mEq/liter
b. Blood glucose of 90 mg/dl
c. Serum creatinine of 5 mg/dl
d Hemoglobin level of 13 grams
Answer: d Hemoglobin level of 13 grams
385. A client who has a history of long-standing back pain treated with methadone
(Dolophine), is admitted to the surgical unit following urological surgery. What modifications
in the plan of care should the nurse make for this client’s pain management during the
postoperative period?
a. Use minimal parenteral opioids for surgical pain, in addition to oral methadone
b. Maintain client’s methadone, and medicate surgical pain based on pain rating
c. Consult with surgeon about increasing methadone in lieu of parenteral opioids
d. Make no changes in standard pain management for this surgery and hold methadone.
Answer: b. Maintain client’s methadone, and medicate surgical pain based on pain rating
386. The nurse applies an automatic external defibrillator (AED) to a client who collapsed in
an exam room at a community clinic. What action should the nurse take next?

a. Determine the defibrillator reading
b. Assess the client’s oxygen saturation
c. Bring a crash cart to the exam room
d. Measure the client’s blood pressure
Answer: b. Assess the client’s oxygen saturation
387. Which change in lab values would indicate to the nurse that treatment for gout is
successful?
a. Decreased serum uric acid
b. Decreased serum purine
c. Increased serum uric acid
d. Increased serum purine
Answer: a. Decreased serum uric acid
388. The nurse reports that a client is at risk for a brain attack (stroke) finding?
a. Jugular vein distention
b. Palpable cervical lymph node
c. Carotid bruit
d. Nuchal rigidity
Answer: d. Nuchal rigidity
389. The nurse is assessing a group of older adults. What factor in a male client’s history puts
him at greatest risk for developing colon cancer?
a. Is excessively exposed to sunlight
b. Eats a high-fat diet
c. Smokes cigars
d. Has intestinal polyps
Answer: d. Has intestinal polyps
390. While taking routine vital signs at 0400 AM, the nurse notes that a client who had a total
knee replacement the previous day has a heart rate of 126 beats/minute. What action should
the nurse take first?
a. Compare heart rate trends with blood pressure trends
b. Review the medical record for a history of cardiac disease

c. Check surgical drainage system and bandage for bleeding
d. Determine current pain level using a 10-point scale
Answer: c. Check surgical drainage system and bandage for bleeding
391. A client who suffered an electrical injury on the left foot is admitted to the burn include
in this client’s plan of care? (incomplete)
a. Assess lung sounds q4 hours
b. Perform passive range of motion
c. Evaluate level of consciousness
d. Continuous cardiac monitoring
Answer: d. Continuous cardiac monitoring
392. The nurse is taking a client’s blood pressure sphygmomanometer cuff is inflated. What
(incomplete)
a. Administer a prescribed PRN antianxiety
b. Assess the client’s recent serum calcium
c. Notify the healthcare provider of the
d. Prepare to implement seizure precautions
ESTA NO TIENE RESPUESTA
Answer: d. Prepare to implement seizure precautions
393. A client with eczema is using an over-the-counter (OTC) topical product with urea 10%
OTC (Aqua Care Cream) to the affected skin areas. Which finding reflects the expected
therapeutic response?
a. Decreased weeping of ulcerations in affected area
b. Healing with a return to normal skin appearance
c. Reduced pain in eczematous areas
d. Hydration of affected dry skin areas
Answer: b. Healing with a return to normal skin appearance
394. During an annual health check, the clinic nurse updates an adult female’s health history.
When discussing the woman’s history of lactose intolerance, the client reports that it has been
years since she last consumed dairy products. What dietary suggestions should the nurse

recommend to help ensure that the client receives an adequate intake of calcium? Select all
that apply:
a. Increase intake of salmon, sardines, tofu, and leafy green vegetables
b. Sip a half-cup of mil during a mid-day meal at least every other day
c. Eat at least six servings of citrus fruits weekly
d. Include 2 to 3 servings of yellow and green squash weekly
e. Take a calcium supplement with vitamin D daily
Answer: b. Healing with a return to normal skin appearance
395. A healthcare worker with no known exposure to tuberculosis has received a Mantoux
tuberculosis skin test. The nurse’s assessment of the test after 72 hours indicates 5mm of
erythema without induration. What is the best initial nursing action?
a. Review client’s history for possible exposure to TB
b. Instruct the client to return for a repeat test in 1 week
c. Refer client to a healthcare provider for isoniazid (INH) therapy
d. Document negative results in the client’s medical record
Answer: a. Review client’s history for possible exposure to TB
396. A male client in skeletal traction tells the nurse that he is frustrated because he needs
help repositioning himself in bed. Which intervention should the nurse implement?
a. Inform the client that it is the nurse’s responsibility to reposition
b. Provide an overhead trapeze to the bed for the client to use
c. Place a draw sheet under the client to assist with repositioning
d. Administer an intravenous PRN anti-anxiety medication
Answer: b. Provide an overhead trapeze to the bed for the client to use
397. In planning care for a client with pneumonia, which nursing problem should the nurse
identify as the priority?
a. Impaired gas exchange related to the effects of alveolar-capillary membrane changes
b. Acute pain related to the effects of inflammation of the parietal pleura
c. Deficient fluid volume related to fever, infection, and increased metabolic rate
d. Disturbed sleep pattern related to pain, dyspnea, and hospitalization
Answer: a. Impaired gas exchange related to the effects of alveolar-capillary membrane
changes

398. A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain.
What is the best initial nursing action?
a. Encourage frequent mouth care
b. Administer a topical analgesic per PRN protocol
c. Cleanse the tongue and mouth with glycerin swabs
d. Obtain a soft diet for the client
Answer: b. Administer a topical analgesic per PRN protocol
399. A client returns from surgery following a hiatal hernia repair via Nissen fundoplication.
Which position should the nurse implement for this client?
a. Right side-lying to promote stomach emptying
b. Prone to apply external pressure to the suture line
c. Left side-lying to reduce stress on the suture
d. Line 30 degree semi-Fowler’s to drop the diaphragm
Answer: d. line 30 degree semi-Fowler’s to drop the diaphragm
400. An adult woman with Grave’s disease is admitted with severe dehydration is currently
restless and refusing to eat. Which action is most important for the nurse to implement?
a. Keep room temperature cool
b. Determine the client’s food preferences
c. Maintain a patent intravenous site
d. Teach the client relaxation techniques
Answer: c. Maintain a patent intravenous site
401. The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit.
Which intervention has the highest priority in providing care for this client?
a. Administer initial dose of broad-spectrum antibiotic
b. Instruct the client to force fluids hourly
c. Obtain results of culture and sensitivity of CSF
d. Assess the client for symptoms of hyponatremia
Answer: c. Obtain results of culture and sensitivity of CSF

402. A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritis
caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema
with purulent exudate at the site. What action should the nurse implement?
a. Schedule an appointment for the client to see the healthcare provider
b. Advise the client to apply plastic wrap over the ointment to promote healing
c. Explain that the client needs to complete all prescribed doses of the medication
d. Instruct the client to continue the ointment until all erythema is relieved
Answer: a. Schedule an appointment for the client to see the healthcare provider
403. During a paracentesis, two liters of fluid are removed from the abdomen of a client with
ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the
first hour. What action should the nurse implement?
a. Palpate for abdominal distention
b. Clamp drainage tube for 5 minutes
c. Continue to monitor the fluid output
d. Send fluid to the lab for analysis
Answer: c. Continue to monitor the fluid output
404. The nurse assesses the dressing of a client who has just returned from post-anesthesia
and finds that the dressing is wet with a moderate amount of bright red bloody drainage.
What action should the nurse take?
a. Replace dressing with a new sterile dressing, and monitor the wound hourly until bleeding
is stopped
b. Call surgery and request that the surgeon see the wound prior to leaving the hospital
c. Reinforce the dressing and document that a moderate amount of sanguineous drainage was
on the dressing
d. Document that the dressing was saturated with serious drainage, and do not change the
dressing
Answer: b. Call surgery and request that the surgeon see the wound prior to leaving the
hospital
405. While the home health nurse is making a home visit, a client with a history of seizures
demonstrates tonic-clonic seizure activity. What action should the nurse implement first?
a. Direct a family member to call emergency services

b. Ascertain the trigger event
c. Protect the client’s head with a pillow
d. Observe the postictal breathing pattern
Answer: c. Protect the client’s head with a pillow
406. A client who weighs 176 pounds is admitted to the intensive care unit with a serum
glucose level of 600 mg/dl and a serum acetone level of 50 mg/dl. Regular insulin at a rate of
0.1unit/kg/hour is prescribed. The pharmacy provides a solution of Regular insulin 100
units/100 ml of normal saline. The nurse should set the infusion pump to deliver how many
ml/hour? (Enter numeric value only)
a. 8ML/H
b. 9ML/H
c. 10ML/H
d. 11ML/H
Answer: a. 8ML/H
407. A client whose history includes IV drug abuse is admitted to the intensive care unit
(ICU) with Kaposi’s sarcoma associated with Acquired Immune Deficiency Syndrome
(AIDS). Which intervention is most important for the nurse to include in the client’s plan of
care?
a. Observe for adverse medication reactions
b. Assess for signs of AIDS dementia
c. Identify signs of opportunistic infections
d. Locate local HIV support groups
Answer: c. Identify signs of opportunistic infections
408. (Photo) The charge nurse observes a newly employed nurse gathering equipment to
obtain a venous blood sample from a client’s implanted port. The nurse has obtained the
equipment seen in the photo. What actions should the charge nurse take? (Select all that
apply)
a. Guide the nurse in inserting the needle at a 45 degree angle
b. Remind the nurse to wear sterile gloves for this procedure
c. Instruct the nurse to obtain several red-topped tubes
d. Determine if the nurse has ever performed this skill

e. Assist in obtaining the correct needle to access the port
Answer: d. Determine if the nurse has ever performed this skill
e. Assist in obtaining the correct needle to access the port
409. After a computer tomography (CT) scan with intravenous contrast medium, a client
returns to the room complaining of shortness of breath and itching. Which intervention
should the nurse implement?
a. Send another nurse for an emergency tracheotomy set
b. Call respiratory therapy to give a breathing treatment
c. Review the client's complete list of allergies
d. Prepare a dose of Epinephrine (Adrenalin ) .
Answer: d. Prepare a dose of Epinephrine (Adrenalin ) .
410. The nurse is reviewing blood pressure readings for a group of client's on a medical unit.
Which client is at the highest risk for complications related to hypertension?
a. Young adult Hispanic female who has a hemoglobin of 11 gm and drinks beer every day
b. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL
c. Older Asian male who eats a diet consisiting of smoked, cured, and pickled foods.
d. Post-menopausal Caucasian female who overeats and is 20% above ideal body weight
Answer: b. Middle-aged African-American male who has a serum creatinine level of 2.9
mg/dL
****PAQUETE QUE EMPIESA CON LEAVE OLD TIES-EL DE ORLIN-YADIRA
Y CONTINUACION DEL HESI MED SURGE PACKAGE QUE NO ESTAN EN
LAS DE ARRIBA .
411. Shingles
Answer: Teach the pt about phantom pain
412. Shingles Select all the apply
Answer: • pain
• ability
• skin integrity

413. Patient w/ ezcema applying cream tto is working:
Answer: Healing With A Return Skin To Normal Appearance.
414. Pt with obesity high glucose level is at risk for?
Answer: Cardiovascular Disease
415. For anemia what doesn’t have iron, which foods are not rich in iron?
Answer: NO ORANGE
416. PT. W/ RISK OF DVT
Answer: Perform Rom Exercises Also Legs Exercise Can Be Other Way To Answer
417. DISCHARGE FOR VENOUS ULCERS SELECT ALL APPLY?
Answer: • Elevate The Feet When Laying Down
• Check Brownish Skin Around The Ankles - Vitamins
Hay Otra Respuesta Por Ahi Que Es Socks En Vez De Vitamins
418. PT W/ SIADH:
Answer: Hard Candy For Thirst.
419. Pt arrive to pacu postop moaning what to do:
Answer: Check Pulse, Bp And Respirations.
420. pt. diagnosed recently w/ dm have not been able to control glucose level during 3 month
what should be done:
Answer: I Put Check For A1c Level (Other Say Assess For What She Have Been Eating 3
Days Ago).
421. When Bp Is High
Answer: Administer (Lasix)
422. Patient w/ esophaegal varices have not be bleeding for 3 days:
Answer: Provide luke warm broth, ice tea and lemon popsicle.

423. CALCULO:
Answer: 0.75
424. Pt With Osteomalcia
Answer: Risk For Injury
425. Sbar—Explain Specific Reason For Urgent Notificaton
Answer: Temperature
426. Intestinal Bowel Obstruction
Answer: Place The Pt 90 Degrees Sitting
427. Osteoarthritis
Answer: Risk For Injury Related To Joint Pain
428. Bone cancer type iv:
Answer: Give opiods- non opiods analgesics.
429. Hypothyroidism
Answer: Restrict Sodium Na 122
430. Pt arrives to clinic w/ nuchal rigidity fever for 6 hours what To do:
Answer: prepare for isolation precautions (i put this one and no lumbar puncture)
431. Intermitent Claudication Teaching
Answer: • Bandage elastic wraped around legs
• Tambien puede salir como pain traction cast notify md (cast no more then 4hr)
432. Preoperative Nursing Care
Answer: • Assess emotional preparedness
• Also can be concerns and anxiety for surgery depende la que pongan
433. Trachestomy care:
Answer: Leave Old Ties On Until New Ones Be On Place Or Secure.

434. Sternal Traction Complains Of
Answer: Pain Administer Prn Meds
435. External Fixation
Answer: • administer prn
• meds
436. Multiple SCLEROSIS (MS)
Answer: Administer Antimedics/ Prn As Needed
437. Female patient how have epigastric pain for 3 days have been Takin antacids and no
resolve arrive to hospital w/hr;128 bpm, bp110/70 what is the most important intervention
finding in assessment:
Answer: Asses For Radiating Jaw Pain.
438. Pt. w. radiactive therapy what to teach/ recommend to
Answer: Protect That Part Of The Skin Specially From The Sun
439. Pt with als what to do to prevent respiratory complications:
Answer: Teach Breathing Tecniques, Uses Spirometer, Auscultate For Breath Or Lung
Sounds.
440. Pt with left lef ulcer:
Answer: Keep Leg Elevated As Much As He Can.
441. Pt with an external device complaining of pain:
Answer: Assess For Pheripheral Pulses.
442. Calculation 1g/0.4 G
Answer: 2.5
443. Examples of dash diet:
Answer: Peel Fruits And Vegetables.

444. Chest tube w/ a drainage changing from clear to green:
Answer: Keep IV Fluids.
445. Pt w/ open angle glaucoma select all that apply:
Answer: Frequent eye exam to asses for vission, use drops to diminsh iop, avoid extrenous
exercices like jogging or running ( yo puse solo esas 3 respuestas).
446. Pt w/ hyperthyroidism developing exosphtalmus:
Answer: Prescribe Tear Eye Drops.
447. Pt vomiting blood like the picture same as hematensis:
Answer: • Check vital signs ( asi esta en todos los papeles)
• Auscultate lungs sounds ( fue lo que puso yadira)
448. Patient w/ ml fell and when receiving the nurse he have 2 projectile vomits what she do:
Answer: Provide Antiemetics Prn .
449. Pt W/ Raynaud Syndrome Which Work As A Data Entry
Answer: clerk: provide a space to warm the enviroment next to her ( algo asi era la
respuesta). Y hay otra respuesta que solo dice keep monitoring
450. Patient that have the k= 6.7 what medication provide:
Answer: Kayelaxate (Treats Hyperkalemia).
451. Colon Cancer
Answer: pt kayelaxate Med
452. Renal Injury
Answer: Kayelaxate Med
453. Pt With A Bronchoscopy And Drink A Glass Of Juice
Answer: Delay The Procedure 6 Hours

454. New patient diagnoses with dm type is receiving teaching in which glucometer will be
the best:
Answer: Asses For Visual Acuity And Ability To Read Or Something Like That.
455. Abg (Ph 7.25 PcO2 50 Sodium 60 Tachy
Answer: And Confusion/ Respiratory
456. Acute agn diet:
Answer: Restrict Na Intake.
457. Pt W/ A Expressive Aphasia Is Anger What Should Do The nurse: cva
Answer: Communicate w/ picture boards.
458. Nurse is teaching the wife if a patient diagnosed w/Seizure what to do:
Answer: Teach Her How To Position Him
459. Pt After TTO Of Something And Wants To
Answer: Eat: nurse assess for bowel movements.
460. SLE:
Answer: Assess For Hematuria
461. Patient allergic to banana (latex):
Answer: Call to md and or staff to be change everything for synthetic materials,
462. Subcut emphysema- toracotomy was a select all that apply:
Answer: Assess For Lung Sounds, Neck Distention I Think It Was And Other Choice That I
Not Remember Now.
463. Restless leg syndrome con feosol:
Answer: Yo Puse Assess For Iron And Ferritin.
464. BNP
Answer: Administrative Furosemide Lasix Iv

465. Parkinson Pt Walking
Answer: Reasure That Stepping On Crackles Is Not Harmful
466. Addison Disease
Answer: Take Corticosteroid Meds
467. Carpo Tonic Syndrome
Answer: Wear Brace In Both Wrist
468. Parkinson And Alzaimers Pt
Answer: Taticardic And Confusion
469. Check Shoes For Diabetic Patients
Answer: For diabetic patients, it is important to check shoes for any signs of irritation,
blisters, or pressure points that could lead to ulcers. This helps prevent potential foot
complications related to neuropathy and poor circulation.
470. Mid Abdomen Burning Pain Peptic Ulcer
Answer: Mid-abdominal burning pain is a common symptom of a peptic ulcer, often
occurring after meals or at night. It may be relieved temporarily by antacids or food but can
worsen without treatment.
471. Antibiotics
Answer: Clear Drainage Improve
472. Alloprinol for Gout
Answer: Take Meds Always
473. Blood Transfusion High Temperature
Answer: Back Pain And Hypotension (Abo- Low Back Pain And Hypotension)
474. Central Fall Risk
Answer: Cardiovascular Disease

475. Right hip fracture
Answer: O2 Sat Level
476. Respiratory Alkalosis (Main Concern)
Answer: Respiratory alkalosis occurs when carbon dioxide levels in the blood decrease due
to rapid breathing, often caused by anxiety, fever, or hyperventilation. It leads to symptoms
like dizziness, numbness, and tingling.
477. Describe Pain Neuropathy
Answer: Nervous System
478. BETA 1.6 CALCULO
Answer: A Beta 1.6 calculation typically refers to a specific test or formula, but the context is
unclear. Could you clarify the full question or provide more details?
479. Acute Abdominal Pain, Nasua, Projectible
Answer: vomiting severe headache and photo sensitivities
480. Urolithisis O Lithotripsy Procedure
Answer: Restrict physical action
481. UAP ( Dice El Paciente Que Tiene Abd Pain Large Tarry Stool
Answer: Test Stool For Occult Blood
482. Insulin for a glucose level of 255 (Pte tmeblando despues que le pusieron insulin.)
Answer: Obtain capillary glucose.
483. NGT proper tube procedure
Answer: Elevate Head 60 to 90 degree
484. RA (rheuma)
Answer: Impaired peripheral mobility relate to join pain.

485. Finger stick glucose finding 50mg
Answer: LOC Level of conscious
486. BMI (una persona que pueden tener colon cancer)
Answer: Large waits circumference with central fat

Med surge Hesi:
487. Q: Parkinson patient walking
Answer: Reassure that stepping on walks’ is not harmful.
488. Q: A male client, who is 24hours
Answer: Auscultate bowel sounds in all four quadrants.
489. Beta 1.6 Math calculo
Answer: To calculate the result for "Beta 1.6, " it depends on the context of the calculation,
such as a specific formula or equation. Please clarify if you need a particular mathematical
operation involving 1.6 or if you are referring to a specific concept like a beta value.
490. Q: Acute abdominal pain, nausea, projectile vomiting
Answer: Severe headache and photo sensitivity
491. Q: Stage IV cancer
Answer: Administration opioids, no opioid meds.
492. MQ: Eczema
Answer: Healing with a return to normal skin appearance.
493. Q: Patient with DVT
Answer: Perform leg exercise.
494. Q: Carpal tunnel
Answer: Wear brace on bath wrist.

495. Q Hypothyroidism Sodium
Answer: 122 mcg/L
496. Q: Epigastric pain-female
Answer: radiating pain to the jaw
497. Q: Ostemalacia Risk for injury.
Answer: Osteomalacia Risk for Injury: The nurse should focus on preventing falls by
ensuring the environment is safe, assisting with ambulation, and encouraging the use of
assistive devices due to weakened bones and muscle weakness associated with osteomalacia.
498. Q: Bronchoscopy (el pte 2 horas antes tomo jugo)
Answer: Delay procedure for 6 hours.
499. Q: Pictine (vomito dentro de un emesis)
Answer: Obtain vital signs.
500. Q: Cancer cells Benign offer the client reassurance that this information indicates that
the clients cancer cells are benign.
Answer: For cancer cells, if they are benign, the nurse should reassure the client that benign
tumors are non-cancerous and generally do not spread to other parts of the body. It’s
important to explain that while benign tumors may still require treatment, they are typically
less harmful than malignant tumors.
501. Q: Cataract
Answer: Light housekeeping is permitted, but avoid heavy lifting.
502. Q: Esophageal varices
Answer: Luke warm bath, cold ice tea, lemon Popsicle.
503. Q: Urolithisi procedure
Answer: Restrict physical action or Stain urine

504. Q: A client who took a camping vacation
Answer: Jaundice sclera.
505. Q: External fixation
Answer: Administrate PRN med.
506. Q: UAP, (dice el pte tiene abd pain, large tarry stool
Answer: Test stool for occult blood.
507. Q: Pheocromocytoma
Answer: Monitor BP.
508. Q: ABD a client experiences an ABD
Answer: Low back pain and hypotension
509. Q: SBAR
Answer: Explain specific reason for urgent notification
510. Q Primary goal of nursing care for pte pre-op
Answer: assess emotional preparedness
511. Q: Intermittent claudication
Answer: wrap elastic bandage around legs.
512. Q TURP
Answer: Drink fluids 3L of water each day.
513. Q: Adult women difficulty time keeping
Answer: Hemoglobin A1C level.
514. Q: CVA:
Answer: encourage use of picture chart. (Boards)
515. Q: Diabetes KAPotassium of

Answer: 2.5
516. Q: Shingles select all that apply
Answer: • Pain
• Ability
• Skin integrity
517. Q: Iron rich, food (pte with anemia cual NO se le va a dar)
Answer: Orange juice
518. Q: MS-multiple sclerosis
Answer: Administration antiemetic.
519. Q: A client diagnoses with stable angina
Answer: Call 911 if pain is unrelieved.
520. Q: BNP
Answer: administrative furosemide Lasix IV.
521. Q: DVT
Answer: calculo: 9
522. Q: An older male client
Answer: Palpate the bladder above the symphysis pubis.
523. Q: Insulin for a glucose level of 255 (Pte tmeblando despues que le pusieron insulin.)
Answer: Obtain capillary glucose.
524. Q: Pte con stiffness neck
Answer: Prepare for lumbar puncture.
525. Q: Shingles
Answer: Check if client was vaccinated for shingles in the past.

526. Q: SIADH:
Answer: Hard candy
527. Q: Tele therapy radiation
Answer: Protect skin from sunlight exposure
528. Q: Tracheostomy
Answer: Leave old ties in place, until new one
529. Q: PACU
Answer: Pulse , BP, respiration.
530. Q: Venous legs ulcer (all that apply)
Answer: Elevate the feet when lying down, Check brownish skin around ankles, vitamins.
531. Q: NGT proper tube procedure
Answer: Elevate dead 60 to 90 degree
532. Q: Xenograft
Answer: The xenograft is from non-human
533. Q: Clean water fluid
Answer: Maintain IV fluid
534. Q: RA (rheuma)
Answer: Impaired peripheral mobility relate to join pain.
535. Q Hemodialysy
Answer: Lower the head of the And elevate feet.
536. Q: A male adult come
Answer: Obtain a sputum samples for culture.
537. Q Finger stick glucose finding 50mg

Answer: LOC Level of conscious
538. Q: BMI (una persona que pueden tener colon cancer)
Answer: Large waits circumference with central fat
539. Q: When explaining dietary guidelines w/ Acute Glomeru
Answer: Restrict sodium intake.

540. Q: Renal injury
Answer: Koyexalate 15 grams PO
541. Q: ABG (PH:7.25-PCO2: 50), Sodium 60
Answer: Tachy and confusion.