HESI EXIT RN EXAM V1-V7 2023
Version 2
1. The husband of an older woman, diagnosed with pernicious anaemia, calls the clinic to
report that his wife still has memory loss and some confusion since she received the first dose
of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be
getting Alzheimer’s disease. What action should the nurse take?
Answer: Explain that memory loss and confusion are common with vitamin B12 deficiency
2. A female client who is admitted to the mental health unit for opiate dependency is
receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of
feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse
identify as a contraindication for administering the medication?
Answer: Blood pressure 90/76 mm Hg
3. During discharge teaching, an overweight client heart failure (HF) is asked to make a
grocery list for the nurse to review. Which food choices included on the client’s list should
the nurse encourage? (Select all that apply)
A. Canned fruit in heavy syrup.
B. Plain, air-popped popcorn.
C. Cheddar cheese cubes.
D. Natural whole almonds.
E. Lightly salted potato chips
Answer: B. Plain, air-popped popcorn.
D. Natural whole almonds.
4. A client with Addison’s disease becomes weak, confused, and dehydrated following the
onset of an acute viral infection. The client’s laboratory values include; sodium 129 mEq/l
(129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When
reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous
medications?
A. Regular insulin.
B. Hydrocortisone
C. Broad spectrum antibiotic
D. Potassium chloride
Answer: B. Hydrocortisone
5. An adolescent, whose mother recently died, comes to the school nurse complain headache.
Which statement made by the students should warrant further explanation nurse?
A. “I’ve had dreams about Mon since she died.”
B. “I’ve been very sad and cry a lot at night.”
C. “I miss Mon and would like to go see her’”.
D. “ it’s hard to concentrate on my homework”
Answer: C. “I miss Mon and would like to go see her’”.
6. When washing soiled hands, the nurse first wets the hands and applies soap. The nurse
should complete additional actions in which sequence? (Arrange from first action on top last
action on bottom.)
1. Rub hands palm to palm.
2. Interlace the fingers,
3. Dry hands with paper towel.
4. Turn off the water faucet.
Answer: 1. Rub hands palm to palm.
2. Interlace the fingers,
3. Dry hands with paper towel.
4. Turn off the water faucet.
7. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the
Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site
contains bright red tissue. What action should the nurse take in response to this finding?
Answer: Document the ongoing wound healing.
8. The nurse is caring for four clients who are on the rehabilitation unit, which client should
the nurse assess first?
A. A client with an above-the-knee amputation who is complaining of phantorn pain.
B. A client who is receiving a continuous tube feeding and is now vomiting.
C. A client with left hemiplegia who is scheduled for haemodialysis today.
D. A client with pneumonia who is scheduled for pulmonary function studies.
Answer: B. A client who is receiving a continuous tube feeding and is now vomiting.
9. A client’s telemetry monitor indicates ventricular fibrillation (VF). After delivering one
counter shock, the nurse resumes chest compression, after another minute of compression ,
the client’s rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this
point , what is the priority intervention for the nurse?
A. Prepare for transcutaneous pacing
B. Administer IV epinephrine per ACLS protocol.
C. Give IV dose of adenosine rapidly over 1-2 seconds.
D. Deliver another defibrillator shock.
Answer: C. Give IV dose of adenosine rapidly over 1-2 seconds.
10. A client with a history of using illicit drugs intravenously is admitted with Kaposi’s
sarcoma.
Which intervention should the nurse include in this client’s admission plan of care?
A. Identify local support HIV support groups.
B. Assess for symptoms of AIDS dementia.
C. Observe for adverse drug reaction.
D. Monitor for secondary infections.
Answer: D. Monitor for secondary infections.
11. After an elderly female client receives treatment for drug toxicity, the HCP prescribes a
24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that
the client’s serum creatinine is 0.3mg/dl. What action should the nurse implement?
A. Initiate the urine collection as prescribed.
B. Notify the HCP of the results.
C. Evaluate the client’s serum BUN level.
D. Assess the client for signs of hypokalaemia.
Answer: B. Notify the HCP of the results.
12. Immediately after extubation, a client who has been mechanically ventilated is placed on
a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which
assessment finding should the nurse report to the healthcare provider immediately?
A. Blood tinged sputum
B. Expiratory wheezing
C. Upper airway stridor
D. Oxygen saturations 90%
Answer: C. Upper airway stridor
13. The nurse is collecting sterile sample for culture and sensitivity from a disposable three
chamber water-seal drainage system connected to a pleural chest tube. The nurse should
obtain the sample from which site on the drainage system?
A. Stopper port located above the water-seal level
B. Plastic tubing located at the chest insertion site
C. Rubberized port at the bottom of collection chamber
D. Tubbing located on the top of the suction chamber
Answer: B. Plastic tubing located at the chest insertion site
14. While the nurse is preparing a scheduled intravenous (IV) medication, the client states
that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site.
Which intervention should the nurse implement?
A. Apply ice first, then a warm compress to the IV site
B. Discontinue the painful IV after a new IV is inserted
C. Review the medical record for the date of insertion
D. Document that the medication was not administered
Answer: B. Discontinue the painful IV after a new IV is inserted
15. During a staff meeting, a nurse verbally attacks the nurse manager conducting the
meeting, stating, “you always let your favorites have holidays off give then easier
assignments. You are unfair and prejudiced” how should the nurse-manager respond?
A. I would prefer to discuss this with you privately.
B. Give me specific examples to support your statements.
C. Does anyone else on the staff fell the same way
D. Your remarks are not true and are very unkind
Answer: B. Give me specific examples to support your statements.
16. An adult is admitted to the emergency department following ingestion of a bottle of
antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous
catheter are placed. The nurse auscultates audible breath sounds on the right side, faint
sounds procedure should the nurse prepare for first?
A. Insertion of a left- sided chest tube.
B. Placement of an endotracheal tube.
C. Retraction of the nasogastric tube
D. Setup of patient- controlled analgesia
Answer: A. Insertion of a left- sided chest tube.
17. A client is admitted to the hospital after experiencing a brain attack, commonly referred to
as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for
speech therapy if the client exhibits which finding?
A. Abnormal responses for cranial nerves I and II
B. Persistent coughing while drinking
C. Unilateral facial drooping
D. Inappropriate or exaggerated mood swings
Answer: B. Persistent coughing while drinking
18. A male client is admitted with a severe asthma attack. For the last 3 hours he has
experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO 2
55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement?
A. Space care to provide periods of rest
B. Instruct client to purse lip breathe
C. Administer PRN dose of albuterol
D. Position client for maximum comfort
Answer: C. Administer PRN dose of albuterol
19. A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis
is hospitalized with basilar crackles and peripheral edema. She is complaining of severe
nausea and the cardiac monitor indicates sinus tachycardia with frequent premature
ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F
which PRN medication should the nurse administers first?
A. Enalapril
B. Furosemide
C. Acetaminophen
D. Promethazine
Answer: B. Furosemide
20. When entering a client’s room to administer an 0900 IV antibiotic, the nurse finds that the
client is engaged in sexual activity with a visitor. Which actions should the nurse implement?
A. Ignore the behavior and hang the IV antibiotic
B. tell the client to stop the inappropriate behavior
C. Leave the room and close the door quietly
D. Complete an unusual occurrence report
Answer: C. Leave the room and close the door quietly
21. The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions
should the nurse implement? (Select all that apply)
A. Ease the client to the floor
B. Loosen restrictive clothing
C. Note the duration of the seizure
Answer: A. Ease the client to the floor
B. Loosen restrictive clothing
C. Note the duration of the seizure
22. A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that
the child may be experiencing digitalis toxicity?
A. Tachycarcia
B. Dyspnea
C. Vomiting
D. Muscle cramps
Answer: C. Vomiting
23. An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the
nurse, “How does this help my GERD?” What is the best response by the nurse?
A. This medication will coat the lining of your esophagus
B. Antacids will neutralize the acid in your stomach
C. It will improve the emptying of food through your stomach
D. antacids decrease the production of gastric secretions
Answer: B. Antacids will neutralize the acid in your stomach
24. The nurse suspect may be haemorrhaging internally. Which findings of an orthostatic test
may indicate to the nurse of major bleed?
Answer: A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart
rate of 20.
25. A male adult is admitted because of an acetaminophen overdose. After transfer to the
mental health unit, the client is told he has liver damage. Which information is most
important for the nurse to include in the client’s discharge plan?
A. Avoid exposure to large crowds 3
B. Do not take any over-the-counter medications
C. Call the crisis hot line if feeling lonely
D. Eat a high carbohydrate, low fat, low protein diet
Answer: A. Avoid exposure to large crowds 3
26. A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When
transferred to the observation unit, the client becomes demanding, aggressive, and shouts at
the staff. Which assessments finding is most important for the nurse to identify in the first 24
hours?
A. Decreased appetite
B. Nausea and elevated blood pressure
C. Difficulty walking
D. Agitation and threats to harms staff
Answer: D. Agitation and threats to harms staff
27. A male client who had a small bowel resection acquired methicillin- resistant
Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is
readmitted today because of diarrhoea and dehydration. It is most important for the nurse to
implement which intervention?
Answer: Maintain contact transmission precautions
28. The nurse applies a blood pressure cuff around a client’s left thigh. To measure the
client’s blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the
loication on one of the images.)
Answer: “On left thigh with arrow pointing to inner thigh”
29. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS),
which instructions should the nurse include in the client’s discharge plan? (Select all that
apply).
A. Practice relaxation exercises
B. Limit fluids to avoid bladder distention
C. Space activities to allow for rest periods
D. Avoid persons with infections
E. Take warm baths before starting exercise
Answer: C. Space activities to allow for rest periods
E. Take warm baths before starting exercise
30. A preoperative client states he is not allergic to any medications. What is the most
important nursing action for the nurse to implement next?
A. Record “no known drug allergies” on preoperative checklist
B. Assess client’s allergies to non-drug substances
C. Assess client’s knowledge of an allergy response
D. Flag “no known drug allergies” on the front of the chart
Answer: C. Assess client’s knowledge of an allergy response
31. During a visit to the planned parenthood clinic, a young woman tells the nurse that she is
going to discontinue taking the oral contraceptives she has taken for three years because she
wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that
she was treated for chlamydia six months ago, which factor in this client’s history poses the
greatest risk for this woman’s pregnancy?
A. Family history of adult onset diabetes.
B. Treatment for chlamydia in the past year
C. Client’s age and previous sexual behavior
D. Three year history of taking oral contraceptives
Answer: A. Family history of adult onset diabetes.
D. Three year history of taking oral contraceptives
32. When conducting diet teaching for a client who was diagnosed with a myocardial
infarction, which snack foods should the nurse encourage the client to eat? (Select all that
apply).
A. Fresh turkey slices and berries
B. Fresh vegetables with mayonnaise dip
C. Soda crackers and peanut butter
D. Chicken bouillon soup and toast
E. raw unsalted almonds and apples
Answer: A. Fresh turkey slices and berries
D. Chicken bouillon soup and toast
E. raw unsalted almonds and apples
33. A mother brings her 3-week-old son to the clinic because he is vomiting “all the time.” In
performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost
20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What
intervention should the nurse implement first?
A. Give the infant 5% dextrose in water orally
B. Insert a nasogastric tube for feeding
C. Initiate a prescribed IV for parental fluid
D. Feed the infant 3 ounces of Isomil
Answer: C. Initiate a prescribed IV for parental fluid
34. An older woman who was recently diagnosed with end stage metastatic breast cancer is
admitted because she is experiencing shortness of breath and confusion. The client refuses to
eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which
intervention is most important for the nurse to implement?
A. Prepare for emergent oral intubation
B. Offer sips of favorite beverages
C. Clarify end of life desires
D. Initiate comfort measures
Answer: C. Clarify end of life desires
35. Which needle should the nurse use to administer intravenous fluids (IV) via a client’s
implanted port?
Answer:
36. The nurse is triaging several children as they present to the emergency room after an
accident. Which child requires the most immediate intervention by the nurse?
A. A 12-year-old with complaints of neck and lower back discomfort
B. An 11-year-old with a headache, nausea, and projectile vomiting
C. A 6-year-old with multiple superficial lacerations of all ectremities
D. An 8-year-old with a full leg air splint for a possible broken tibia
Answer: B. An 11-year-old with a headache, nausea, and projectile vomiting
37. An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers
spasms when taking the blood pressure using the same arm. After confirming the presence of
spams what action should the nurse take?
A. Ask the UAP to take the blood pressure in the other arm
B. Tell the UAP to use a different sphygmomanometer.
C. Review the client’s serum calcium level
D. Administer PRN antianxiety medication.
Answer: C. Review the client’s serum calcium level
38. The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing
the side of a cliff and has been in a sustained vegetative state since the accident. Which
intervention should the nurse implement?
A. Inquire about food allergies and food likes and dislikes
B. Talk directly to the adolescent while providing care
C. Initiate open communication with the teen’s parents
D. Monitor vital signs and neuro status every 2 hours
Answer: B. Talk directly to the adolescent while providing care
C. Initiate open communication with the teen’s parents
39. Following an open reduction of the tibia, the nurse notes bleeding on the client’s cast.
Which action should the nurse implement?
A. No action is required since postoperative bleeding can be expected
B. Lower the client’s head while assessing for symptoms of shock
C. Call the health care provider and prepare to take the client back to the operating room
D. Outline the area with ink and check it every 15 minutes to see if the area has increased
Answer: D. Outline the area with ink and check it every 15 minutes to see if the area has
increased
40. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood
pressure readings are taken so often. Which response by the nurse is most accurate?
A. Blood pressure fluctuations means that the condition has become chronic
B. Elevated blood pressure must be anticipated and identified quickly
C. Hypotension leading to sudden shock can develop at any time
D. Sodium intake with meals and snacks affects the blood pressure
Answer: B. Elevated blood pressure must be anticipated and identified quickly
41. The mother of a child recently diagnosed with asthma asks the nurse how to help protect
her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which
instructions should the nurse provide the mother? (Select all that apply)
A. Close car windows and use air conditioner
B. Avoid sudden changes in temperature
C. Keep away from pets with long hair
D. Stay indoors when grass is being cut
Answer: A. Close car windows and use air conditioner
B. Avoid sudden changes in temperature
C. Keep away from pets with long hair
D. Stay indoors when grass is being cut
42. Which client should the charge nurse on the oncology unit assign to an RN, rather than a
practical nurse (PN)?
Answer: An elderly female client with cancer whose children who are trying to decide
whether to change to palliative care measures or continue disease control
43. An elderly male client is admitted to the urology unit with acute renal failure due to a
postrenal obstruction. Which questions best assists the nurse in obtaining relevant historical
data?
A. “Have you had a heart attack in the last 6 months”
B. “Have you had any difficulty in starting your urinary stream”
C. “Have you taken any antibiotics recently”
D. “Have you received any blood products in the last year”
Answer: B. “Have you had any difficulty in starting your urinary stream”
44. A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In
what position should the nurse place the child?
Answer: Sitting up and leaning forward
45. A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has
the best prognosis with which treatment regimen?
A. Bone marrow transplantation
B. Blood transfusion
C. Chemotherapy
D. Immunosuppressive therapy
Answer: A. Bone marrow transplantation
46. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a
bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to
take further action?
Answer: Tented skin turgor
47. An unconscious client is admitted to the intensive care unit and is placed on a ventilator.
The ventilator alarms continuously and the client's oxygen saturation level is 62%. What
action should the nurse take first?
Answer: Begin manual ventilation immediately.
48. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency
with incontinence. Which action should the nurse implement?
Answer: Obtain a clean catch mid-stream specimen
49. A client’s subjective data includes dysuria, urgency, and urinary frequency. What action
should the nurse implement next?
Answer: Collect a clean-catch specimen
50. A client is admitted with an exacerbation of heart failure secondary to COPD. Which
observations by the nurse require immediate intervention to reduce the likelihood of harm to
this client? (Select all that apply).
A. A bedside commode is positioned near the bed
B. A saline lock is present in the right forearm
C. A full pitcher of water is on the bedside table
D. The client is lying in a supine position in bed
E. A low sodium diet tray was brought to the room
Answer: C. A full pitcher of water is on the bedside table
D. The client is lying in a supine position in bed
51. A client with a traumatic brain injury becomes progressively less responsive to stimuli.
The client has a “Do Not Resuscitate” prescription, and the nurse observes that the unlicensed
assistive personnel (UAP) has stopped turning the client from side to side as previously
schedules. What action should the nurse take?
A. Advise the UAP to resume positioning the client on schedule
B. Encourage the UAP to provide comfort care measures only
C. Assume total care of the client to monitor neurologic function
D. Assign a practical nurse to assist the UAP in turning the client
Answer: A. Advise the UAP to resume positioning the client on schedule
52. The nurse reviews the laboratory findings of a client with an open fracture of the tibia.
The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated.
Before reporting this information to the healthcare provider, what assessment should the
nurse obtain?
A. Degree of skin elasticity
B. Appearance of wound
C. Bilateral pedal pulse force
D. Onset of any bleeding
Answer: B. Appearance of wound
53. The HCP prescribes methotrexate 7.5 mg PO weekly, in 3 divides 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 weekly? (Enter the numeric value only. If round is required, round to
the nearest tenth.)
Answer:1.5
54. An alert older client with diabetes mellitus type 1 is admitted with a serum glucose of 420
mg/dl (23.31 mmol/L (SI)). As the nurse administers 10 units of regular insulin intravenous
(IV), the client immediately begins to vomit. What action should the nurse implement first?
Answer: Turn the client to a lateral position
55. A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction.
When preparing to insert a nasogastric (NG) tube, which intervention should the nurse
implement?
A. Elevate the head of the bed 60 to 90 degrees
B. Measure from corner of mouth to angle of jaw
C. Administer a PRN analgesic
D. Assess for a gag reflex
Answer: A. Elevate the head of the bed 60 to 90 degrees
56. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of
increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is
breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to
start taking them again because of her increased anxiety. What response is best for the nurse
to provide this woman?
Answer: Inform her that some antianxiety medications are safe to take while breastfeeding
57. At the end of a preoperative teaching session on pain management techniques, a client
starts to cry and states, “I just know I can’t handle all the pain.” What is the priority nursing
diagnosis for this client?
Answer: Anxiety
58. In early septic shock states, what is the primary cause of hypotension?
A. Cardiac failure
B. A vagal response
C. Peripheral vasoconstriction
D. Peripheral vasodilation
Answer: D. Peripheral vasodilation
59. The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter.
The new nurse has gathered supplies, including intravenous catheters, an intravenous
insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What
action should the charge nurse take?
A. Plan to observe the secured IV site after the insertion procedure
B. Confirm that the nurse has gathered the necessary supplies
C. Remind the nurse to tape the gauze dressing securely in place
D. Instruct the nurse to use a transparent dressing over the site
Answer: B. Confirm that the nurse has gathered the necessary supplies
D. Instruct the nurse to use a transparent dressing over the site
60. An adult client comes to the clinic and reports his concern over a lump that “just popped
up on my neck about a week ago.” In performing an examination of the lump, the nurse
palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying
tissue inflammation. What do these finding suggest?
A. Bacterial infection
B. Lymphangitis
C. Malignancy
D. Viral infection
Answer: C. Malignancy
61. The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary
tract infection. Which client data requires the most immediate intervention by the nurse?
A. Urine culture positive for MRSA
B. Serum sodium of 145 mEq/L (145 mmol/L SI)
C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI)
D. White blood cell count of of 12,000 mm3 (12 x 109/L SI)
Answer: C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI)
62. The unit clerk reports to the charge nurse that a healthcare provider has written several
prescriptions that are illegible and it appears the healthcare provider used several unapproved
abbreviations in the prescriptions. What actions should the charge nurse take?
A. Complete and file an incident (variance) report
B. Call the healthcare provider who wrote the prescription
C. Contact the healthcare provider review board for instructions
D. Report the situation to the house supervisor
Answer: B. Call the healthcare provider who wrote the prescription
D. Report the situation to the house supervisor
63. A confused, older client with Alzheimer’s disease becomes incontinent of urine when
attempting to find the bathroom. Which action should the nurse implement?
A. Instruct the client to use the call button when a bedpan is needed
B. Apply adult diapers after each attempt to void
C. Check residual urine volume using an indwelling urinary catheter
D. Assist the client’s to a bedside commode every two hours
Answer: D. Assist the client’s to a bedside commode every two hours
64. The nurse discovers that an elderly client with no history of cardiac or renal disease has
an elevated serum magnesium level. To further investigate the cause of this electrolyte
imbalance, what information is most important for the nurse to obtain from the client’s
medical history?
Answer: Frequency of laxative use for chronic constipation
65. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which
nursing actions should the nurse assign to the PN? (Select all that apply.)
A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus
(DM).
B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
D. Initiate patient controlled analgesia (PCA) pumps for two clients immediately
postoperative
E. Start the second blood transfusion for a client twelve hours following a below knee
amputation
Answer: A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes
mellitus (DM).
B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
66. In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which
assessment finding is most important for the nurse to report to the healthcare provider?
A. Watery diarrhea
B. Yellow-tinged sputum
C. Increased fatigue
D. Nausea and headache
Answer: A. Watery diarrhoea
67. The nurse is preparing to mix two medications from two different multidose vials, A and
B.
In which order should these actions be implemented when drawing the solutions from the
vials?
(Arrange from first on top to last on the bottom)
A. Verify the drug and dose with the label on the vial
B. Inject the volume of air to be aspirated from each vial
C. Aspirate the desired volume from vial A
D. Aspirate the desired volume from vial B
Answer: A. Verify the drug and dose with the label on the vial
B. Inject the volume of air to be aspirated from each vial
C. Aspirate the desired volume from vial A
D. Aspirate the desired volume from vial B
68. An 11-year-old client is admitted to the mental health unit after trying to run away from
home and threatening self-harm. The nurse establishes a goal to promote effective coping,
and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to
establish rapport and accomplish this therapeutic goal?
A. Bring the client to the team meeting to discuss the treatment plan
B. Ask the client to write feeling in a journal and then review it together
C. Explain the purpose of each medication the client is currently taking
D. Play a board game with the client and begin taking about stressors
Answer: D. Play a board game with the client and begin taking about stressors
69. An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic
medications refuses a prescribed IM medication. Which action should the nurse take?
A. Notify the healthcare provider of the client’s refusal
B. Administer an oral PRN medication for agitation
C. Ask for staff assistance with administering the injection
D. explain that oral medications will no longer be required
Answer: A. Notify the healthcare provider of the client’s refusal
70. An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis
comes to the clinic with a bag of medication bottles. Which intervention should the nurse
implement first?
A. Record pain evaluation
B. Assess blood glucose
C. Identify pills in the bag
D. Obtain a medical history
Answer: C. Identify pills in the bag
71. A male client with an antisocial personality disorder is admitted to an in-patient mental
health unit for multiple substance dependency. When providing a history, the client justifies
to the nurse his use of illicit drugs. Based on this pattern of behavior this client’s history is
most likely to include which finding?
A. Phobias and panic attacks when confronted by authority figures.
B. Suicidal ideations and multiple attempts/
C. Multiple convictions for misdemeanours and class B felonies.
D. Delusions of grandiosity and persecution
Answer: C. Multiple convictions for misdemeanours and class B felonies.
72. An adult male who fell from a roof and fractures his left femur is admitted for surgical
stabilization after having a soft cast applied in the emergency department. Which assessment
finding warrants immediate intervention by the nurse?
A. Onset of mild confusion
B. Pain score 8 out of 10
C. Pale, diaphoretic skin
D. Weak palpable distal pulses
Answer: D. Weak palpable distal pulses
73. A client who has a suspected brain tumour is schedules for a computed (CT) scan. When
preparing the client for the client for the CT scan, which intervention should the nurse
implement?
A. Determine if the client has had a knee or hip replacement
B. Immobilize the client’s neck before moving onto stretcher
C. Give an antiemetic to control nausea
D. Obtain the client’s food allergy history
Answer: D. Obtain the client’s food allergy history
74. A client who is at 10-weeks gestation calls the clinic because she has been vomiting for
the past 24 hours. The nurse determines that the client has no fever. Which instructions
should the nurse give to this client?
A. Remain on clear liquids until the vomiting subsides
B. Come to the clinic to be seen by a healthcare provider
C. Make an appointment at the clinic if a fever occurs
D. Take nothing by mouth until there is no more nausea
Answer: D. Take nothing by mouth until there is no more nausea
75. The nurse is preparing to gavage feed a premature infant through an orogastric tube.
During insertion of the tube, the infant’s heart rate drops to 60 beats / minute. Which action
should the nurse take?
A. Continue the insertion since this is a typical response
B. pause and monitor for a continues drop of the heart rate
C. Insert the feeding tube into the infant’s nasal passage
D. Postpone the feeding until the infant’s vital signs and stable
Answer: D. Postpone the feeding until the infant’s vital signs and stable
76. An infant is receiving gavage feedings via nasogastric tube. At the beginning of the
feeding, the infant’s heart rate drops to 80 beats / minute. What action should the nurse take?
Answer: Slow the feeding and monitor the infant’s response.
77. A male client is admitted with a bowel obstruction and intractable vomiting for the last
several hours despite the use of antiemetics. Which intervention should the nurse implement
first? (Please scroll and view each tab’s information in the client’s medical record before
selecting the answer.)
A. Infuse 0.9 % sodium chloride 500 ml bolus
B. Insert nasogastric tube to intermittent suction.
C. Maintain head of bed at 45 degrees
D. Document strict intake and output
Answer: A. Infuse 0.9 % sodium chloride 500 ml bolus
78. While removing staples from a male client’s postoperative wound site, the nurse observes
that the client’s eyes are closed and his face and hands are clenched. The client states, “I just
hate having staples removed.” After acknowledging the client’s anxiety, what action should
the nurse implement?
Answer: Attempt to distract the client with general conversation
79. A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On
examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood
pressure. Which intervention should the nurse implement first?
A. Ensure client takes a diuretic q AM
B. Obtain serum creatinine levels daily
C. Measure ankle circumference
D. Monitor daily sodium intake
Answer: A. Ensure client takes a diuretic q AM
80. The nurse and an unlicensed assistive personnel (UAP) are providing care for a client
with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage
this situation?
A. Determine the presence of hematemesis as the UAP irrigates the NGT
B. Instruct the UAP to bring an antiemetic to the nurse at the bedside
C. Assess the appearance of the emesis while the UAP checks bowel sounds
D. Direct the UAP to measure the emesis while the nurse irrigates the NGT
Answer: D. Direct the UAP to measure the emesis while the nurse irrigates the NGT
81. A preschooler with constipation needs to increase fiber intake. Which snack suggestion
should the nurse provide?
A. soft pretzels
B. fruit-flavored yogurt
C. oatmeal cookies
D. low fat cheese sticks
Answer: C. oatmeal cookies
82. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper
area is excoriated and red, but there are no blisters or bleeding. The mother reports no
evidence of watery stools. Which nursing intervention should the nurse implement?
A. Instruct the mother to change the child’s diaper more often.
B. Encourage the mother to apply lotion with each diaper charge
C. Tell the mother to cleanse with soap and water at each diaper change
D. Ask the mother to decrease the infant’s intake of fruits for 24 hours.
Answer: A. Instruct the mother to change the child’s diaper more often.
83. After multiple attempts to stop drinking, an adult male is admitted to the medical
intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless,
and disoriented. Which finding indicates a life- threatening condition?
A.CIWA-Ar for alcohol withdrawal score of 30
B. Acute onset of unrelenting chest pain
C. Widening QRS complexes and flat waves
D. Intense tremor and involuntary muscle activity
Answer: C. Widening QRS complexes and flat waves
84. The home health nurse is preparing to make daily visits to a group of clients. Which client
should the nurse visit first?
A. A client with congestive heart failure who reports a 3 pound weight gain in the last two
days
B. An immobile client with a stage 3 pressure ulcer on the coccyx who is having low back
pain
C. A client diagnosed with chronic obstructive pulmonary disease (COPD) who is short of
breath
D. A terminally ill older adult who has refused to eat or drink anything for the last 48 hours
Answer: A. A client with congestive heart failure who reports a 3 pound weight gain in the
last two days
C. A client diagnosed with chronic obstructive pulmonary disease (COPD) who is short of
breath
85. A female client is admitted for diabetic crisis resulting from inadequate dietary practices.
After stabilization, the nurse talks to the client about her prescribed diet. What client
characteristic is most import for successful adherence to the diabetic diet?
A. Knows that insulin must be given 30 min before eating
B. Frequently eats fruits and vegetables at meals and between meals/
C. Has someone available who can prepare and oversee the diet
D. Demonstrates willingness to adhere to the diet consistently
Answer: D. Demonstrates willingness to adhere to the diet consistently
86. A client currently receiving an infusion labelled Heparin Sodium 25,000 Units in 5%
Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the
infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver
how many mL/hour? (Enter numeric value only).
Answer: 700
Rationale:
D/H x Q = 25000 / 500 x 14 = 700
87. Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with
pneumonia. When planning care for this child, what principle of oxygen administration
should the nurse consider?
A. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen?
B. Avoid administration of oxygen at high levels for extended periods.
C. Increase oxygen rate during sleep to compensate for slower respiratory rate.
D. Oxygen is less toxic when it is humidified with a hydration source.
Answer: B. Avoid administration of oxygen at high levels for extended periods.
88. The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin
therapy the client’s serum blood potassium is elevated, which finding requires immediate
action by the nurse?
A. Tall peak T waves on the cardiac monitor
B. Peripheral pitting edema at 2 + indentation
C. Serum creatinine above 0.5 mg/dl or 44.2 micro-mmol/dl
D. Anuria for the last 12 hours.
Answer: D. Anuria for the last 12 hours.
89. A client presents to the labor and delivery unit, screaming “THE BABY IS COMING”
which action should the nurse implement first.
Answer: Observe the perineum
VIDEO
90. During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a
skills class, as seen in the video. After the demonstration, the supervising nurse expresses
concern that the demonstrated procedure increased the client’s risk for which problem?
A. Infection
B. Ineffective airway clearance
C. Altered comfort
D. Impaired gas exchange
Answer: A. Infection
91. One day after abdominal surgery, an obese client complains of pain and heaviness in the
right calf. What action should the nurse implement?
Answer: Observe for unilateral swelling
92. A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports
to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish
cast to his skin. What instructions should the nurse provide?
A. “You have become dehydrated from the nausea. You will need to rest and increase fluid
intake”
B. “you need to seek immediate medical assistance to evaluate the cause of these symptoms”
C. A urine specimen will be needed to determine what kind of infection you have developed”
D. use insulin per sliding scale until the nausea resolves, and then resume your oral
medication”
Answer: B. “you need to seek immediate medical assistance to evaluate the cause of these
symptoms”
93. A male client with ulcerative colitis received a prescription for a corticosteroid last month,
but because of the side effect he stopped taking the medication 6 year ago. Which finding
warrants immediate intervention by the nurse?
A. Hypotension and fever
B. Anxiety and restlessness.
C. Fluid retention
D. Increased blood glucose.
Answer: B. Anxiety and restlessness.
94. A client in the intensive care unit is being mechanically ventilated, has an indwelling
urinary catheter in place, an exhibiting signs of restlessness. Which action should the nurse
take fist?
A. Administer PRN dose of lorazepam
B. Auscultate bilateral breath sounds
C. Check urinary catheter for obstruction
D. Review the heart rhythms on cardiac monitor.
Answer: B. Auscultate bilateral breath sounds
95. A young adult female client with recurrent pelvic pain for 3 year returns to the clinic for
relief of severe dysmenorrhea. 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. The symptoms of endometriosis can increase with menopause.
C. An option to diagnose disease extent and provide therapeutic treatment is laparoscopy.
D. Infertile is successfully treated with removal of intra-abdominal endometrial lesions.
Answer: A. Oral contraceptives increase the symptoms of endometriosis.
96. A 75-year-old female client is admitted to the orthopedic unit following an open reduction
and internal fixation of a hip fracture. On the second postoperative day, the client becomes
confused and repeatedly asks the nurse she is. What information for the nurse to obtain?
A. Use of sleeping medications.
B. History of alcohol use,
C. Use of antianxiety medications,
D. History of this behavior.
Answer: B. History of alcohol use,
97. To reduce the risk of being named in malpractice lawsuit, which action is most important
for the nurse to take?
A. Establish a trusting nurse-client relationship.
B. Complete an incident report following a client injury.
C. Maintain current professional malpractice insurance,
D. Adhere consistently to standards of care.
Answer: D. Adhere consistently to standards of care.
98. A client with multiple sclerosis is receiving beta-1b interferon every other day. To assess
for possible bone marrow suppression caused by the medication, which serum laboratory test
findings should the nurse monitor? (Select all that apply)
A. Platelet count
B. Red blood cell count (RBC)
C. White blood cell count (WBC).
D. Albumin and protein
E. Sodium and potassium
Answer: A. Platelet count
B. Red blood cell count (RBC)
C. White blood cell count (WBC).
99. Which assessment is more important for the nurse to include in the daily plan of care for a
client with a burned extremity?
Answer: Distal pulse intensity
VIDEO
100. The nurse is auscultating a client’s lung sounds. Which description should the nurse use
to document this sound?
(Please listen to the audio file to select the option that applies.)
https://www.youtube.com/watch?v=VGDdqtIhUdA
A. High pitched or fine crackles.
B. High pitched wheeze
C. Rhonchi
D. Stridor
Answer: A. High pitched or fine crackles.
101. The nurse needs to add a medication to a litre of 5% Dextrose in Water (D5W) that is
already infusing into a client. At what location should the nurse inject the medication?
Answer:
102. The nurse is assessing and elderly bedridden client. Which finding indicates that the
turning and positioning schedule is effective in protecting the client’s skin?
A. Reddened skin areas disappear within 15 minutes of being turned and positioned.
B. No complaints of pressure or pain are verbalized by the client after being turned
C. Only small areas of redness remain longer than 30 min after the client is turned.
D. The client verbalizes feeling better after being turned and positioned
Answer: A. Reddened skin areas disappear within 15 minutes of being turned and positioned.
103. A client with a liver abscess develops septic shock. A sepsis resuscitation bundle
protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the
nurse monitor to assess effectiveness of the fluid bolus?
A. Mean arterial pressure (MAP)
B. White blood cell count
C. Blood culture
D. Oxygen saturation
Answer: D. Oxygen saturation
104. A 17-year –old male is brought to the emergency department by his parents because he
has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which
intervention should the nurse implement first?
A. Obtain a chest X-ray per protocol.
B. Place a mask on the client’s face.
C. Assess the client’s temperature.
D. Determine the client’s blood pressure
Answer: B. Place a mask on the client’s face.
105. An older client is admitted for repair of a broken hip. To reduce the risk for infection in
the postoperative period, which nursing care interventions should the nurse include in the
client’s plan of care? (Select all that apply)
A. Teach client to use incentive spirometer q2 hours while awake.
B. Remove urinary catheter as soon as possible and encourage voiding.
C. Maintain sequential compression devices while in bed.
D. Administer low molecular weight heparin as prescribed
E. Assess pain level and medicate PRN as prescribed.
Answer: A. Teach client to use incentive spirometer q2 hours while awake.
B. Remove urinary catheter as soon as possible and encourage voiding.
106. A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after
receiving chemotherapy. The client has saline lock and is sleeping quietly without any
restlessness. The nurse caring for the client is not certified in chemotherapy administration.
What action should the nurse take?
A. Ask a chemotherapy-certified nurse to administer the Zofran
B. Administer the ondasentron (Zofran) after flushing the saline lock with saline
C. Hold the scheduled dose of Zofran until the client awakens
D. Awaken the client to assess the need for administration of the Zofran.
Answer: B. Administer the ondasentron (Zofran) after flushing the saline lock with saline
107. The nurse note a visible prolapse of the umbilical cord after a client experiences
spontaneous rupture of the membranes during labor. What intervention should the nurse
implement immediately?
Answer: Elevate the presenting part off the cord.
108. While visiting a female client who has heart failure (HF) and osteoarthritis, the home
health nurse determines that the client is having more difficulty getting in and out of the bed
than she did previously.
Which action should the nurse implement first?
A. Inquire about an electric bed for the client’s home use
B. Submit a referral for an evaluation by a physical therapist.
C. Explain the usual progression of osteoarthritis and HF
D. Request social services to review the client’s resources.
Answer: B. Submit a referral for an evaluation by a physical therapist.
109. A client is admitted to a mental health unit after attempting suicide by taking a handful
of medications. In developing a plan of care for this client, which goal has the highest
priority?
A. Signs a no-self-harm contract.
B. Sleep at least 6 hours nightly.
C. Attends group therapy every day
D. Verbalizes a positive self-image.
Answer: A. Signs a no-self-harm contract.
110. The nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this
point in the procedure, what actions should the nurse take before inserting the catheter?
(Select all that apply)
A. Ask the client to bear down as if voiding to relax the sphincter
B. Complete perianal care with soap and water
C. Gently palpate the client’s bladder for distention
D. Hold the catheter 3 – 4 inches (7.5 – 10 cm) from its tip
E. Secure the urinary drainage bag to the bed frame
Answer: C. Gently palpate the client’s bladder for distention
D. Hold the catheter 3 – 4 inches (7.5 – 10 cm) from its tip
E. Secure the urinary drainage bag to the bed frame
