HESI exam 2024 100 out of 100
16 July 2024HESI exam 2024 100 out of 100
66. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?
A) Sedative hypnotics are effective analgesics
B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
C) Caffeine beverages can increase the effect of sedative hypnotics D) Avoidance of excessive exercise and high temperature is recommended
The correct answer is B: Sudden cessation of alprazolam 67. A client has received 2 units of whole blood today following an episode of GI
bleeding. Which of the following laboratory reports would the nurse monitor most closely? A) Bleeding time
B) Hemoglobin and hematocrit
C) White blood cells
D) Platelets
The correct answer is B: Hemoglobin and hematocrit 68. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?
A) Protamine
B) Amicar
C) Imferon
D) Diltiazem
The correct answer is A: Protamine . Protamine binds heparin making it ineffective.
69. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus.
Which statement by the client indicates a need for further teaching?
A) “I use a sliding scale to adjust regular insulin to my sugar level.”
B) “Since my eyesight is so bad, I ask the nurse to fill several syringes.”
C) “I keep my regular insulin bottle in the refrigerator.”
D) “I always make sure to shake the NPH bottle hard to mix it well.” The correct answer is D: “I always make sure to shake the NPH bottle hard to mix it well.”
70. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?
A) Orthostatic hypotension is a common side effect
B) Most antipsychotic drugs cause elevated blood pressure
C) This provides information on the amount of sodium allowed in the diet
D) It will indicate the need to institute anti parkinsonian drugs The correct answer is A: Orthostatic hypotension is a common side effect
71. The nurse is teaching the client to select foods rich in potassium to help prevent
digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots
B) Medium banana
C) Naval orange
D) Baked potato
The correct answer is D: Baked potato.
72. An 86 year-old nursing home resident who has decreased mental status is hospitalized
with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a
clear liquid diet, the client begins to cough. What should the nurse do next?
A) Add a thickening agent to the fluids
B) Check the client’s gag reflex
C) Feed the client only solid foods
D) Increase the rate of intravenous fluids
The correct answer is B: Check the client’s gag reflex
73. The nurse is planning care for a client with a CVA. Which of the following measures
planned by the nurse would be most effective in preventing skin breakdown?
A) Place client in the wheelchair for four hours each day
B) Pad the bony prominence
C) Reposition every two hours
D) Massage reddened bony prominence
The correct answer is C: Reposition every two hours
74. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
A) A 79 year-old malnourished client on bed rest
B) An obese client who uses a wheelchair
C) A client who had 3 incontinent diarrhea stools
D) An 80 year-old ambulatory diabetic client
The correct answer is A: A 79 year-old malnourished client on bed rest
75. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse’s priority?
A) Obtain a complete blood count
B) Obtain a health and dietary history
C) Refer to a provider for a physical examination
D) Measure height and weight
The correct answer is B: Obtain a health and dietary history 76. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
A) Abdominal x-ray
B) Auscultation
C) Flushing tube with saline
D) Aspiration for gastric contents
The correct answer is A: Abdominal x-ray
77. A client was just taken off the ventilator after surgery and has a nasogastric tube
draining bile colored liquids. Which nursing measure will provide the most comfort to the client?
A) Allow the client to melt ice chips in the mouth
B) Provide mints to freshen the breath
C) Perform frequent oral care with a tooth sponge
D) Swab the mouth with glycerin swabs
The correct answer is C: Perform frequent oral care with a tooth sponge
78. The nurse is instructing a 65 year-old female client
diagnosed with osteoporosis. The
most important instruction regarding exercise would be to
A) Exercise doing weight bearing activities
B) Exercise to reduce weight
C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones The correct answer is A: Exercise doing weight bearing activities
79. The nurse has been teaching a client with congestive heart failure about proper
nutrition. The selection of which lunch indicates the client has learned about sodium restriction?
A) Cheese sandwich with a glass of 2% milk
B) Sliced turkey sandwich and canned pineapple
C) Cheeseburger and baked potato
D) Mushroom pizza and ice cream
The correct answer is B: Sliced turkey sandwich and canned pineapple
80. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol?
A) All 4 side rails up, wheels locked, bed closest to door
B) Lower side rails up, bed facing doorway
C) Knees bent, head slightly elevated, bed in lowest position
D) Bed in lowest position, wheels locked, place bed against wall The correct answer is D: Bed in lowest position, wheels locked, place bed against wall
81. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
A) Every four to six hours
B) Continuously
C) In a bolus
D) Every hour
The correct answer is B: Continuously
82. The nurse is teaching an 87 year-old client methods for maintaining regular bowel
movements. The nurse would caution the client to AVOID
A) Glycerine suppositories
B) Fiber supplements
C) Laxatives
D) Stool softeners
The correct answer is C: Laxatives
83. A client with diarrhea should avoid which of the following?
A) Orange juice
B) Tuna
C) Eggs
D) Macaroni
The correct answer is A: Orange juice
84. Which statement best describes the effects of immobility in children?
A) Immobility prevents the progression of language and fine motor development
B) Immobility in children has similar physical effects to those found in adults
C) Children are more susceptible to the effects of immobility than are adults
D) Children are likely to have prolonged immobility with subsequent complications
The correct answer is B: Immobility in children has similar physical effects to those found in adults
85. A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client’s comfort?
A) Increase oral fluid intake
B) Encourage visits from family and friends
C) Keep conversations short
D) Monitor vital signs frequently
The correct answer is C: Keep conversations short
86. After a myocardial infarction, a client is placed on a sodium restricted diet. When the
nurse is teaching the client about the diet, which meal plan would be the most appropriate
A) 3 oz. broiled fish, 1 baked potato, . cup canned beets, 1 orange, and milk
B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
The correct answer is D: 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
87. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings
include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
A) Decreased carbohydrates and fat
B) Decreased sodium and potassium
C) Increased potassium and protein
D) Increased sodium and fluids
The correct answer is B: Decreased sodium and potassium 88. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A) Presence of blood in stools
B) Oozing liquid stool
C) Continuous rumbling flatulence
D) Absence of bowel movements
The correct answer is B: Oozing liquid stool
89. A client in a long term care facility complains of pain. The nurse collects data about
the client’s pain. The first step in pain assessment is for the nurse to
A) have the client identify coping methods
B) get the description of the location and intensity of the pain
C) accept the client’s report of pain
D) determine the client’s status of pain
The correct answer is C: Accept the client'’s report of pain 90. An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be
A) Assess the severity and location of the pain
B) Obtain an order for an analgesic
C) Reassure him that this is not unusual for his age
D) Encourage him to increase his activity
The correct answer is A: Assess the severity and location of the pain
91. A 20 year-old client has an infected leg wound from a motorcycle accident, and the
client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact
precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) Visitors must wear a mask and a gown
B) There are no special requirements for visitors of clients on contact precautions
C) Visitors should wash their hands before and after touching the client
D) Visitors
The correct answer is C:Visitors should wash their hands before and after touching the client
92. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?
A) Institute seizure precautions
B) Monitor neurologic status every hour
C) Placein respiratory/secretion precautions
D) Cefotaxime IV 50 mg/kg/day divided q6h
The correctanswer is C:Place in respiratory/secretionprecautions 93. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?
A) Sensory perceptual alterations related to decreased vision
B) Alteration in mobility related to fatigue
C) Impaired gas exchange related to retained secretions
D) Altered patterns of urinary elimination related to nocturia The correct answer is D: Altered patterns of urinary elimination related to nocturia
94. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A) An infant who has been identified to have botulism
B) A toddler who ate a number of ibuprofen tablets
C) A preschooler who swallowed powdered plant food
D) A school aged child who took a handful of vitamins The correct answer is A: An infant who has been identified to have botulism
95. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should
reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?
A) Apply appropriate signs outside and inside the room
B) Apply a mask with a shield if there is a risk of fluid splash
C) Wear a gown to change soiled linens from incontinence
D) Have gloves on while handling bedpans with feces
The correct answer is D: Have gloves on while handling bedpans with feces
96. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?
A) An infant with a positive culture of stool for Shigella
B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles
on an erythematous base that appear on the skin
The correct answer is B: An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
97. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia.
What type of isolation is most appropriate for this client?
A) Reverse
B) Airborne
C) Standard precautions
D) Contact
The correct answer is D: Contact
98. The school nurse is teaching the faculty the most effective methods to prevent the
spread of lice in the school. The information that would be most important to include would be which of these statements?
A) ”The treatment requires reapplication in 8 to 10 days." B) ”Bedding and clothing can be boiled or steamed."
C) Children are not to share hats, scarves and combs.
D) Nit combs are necessary to comb out nits.
The correct answer is C: “Children are not to share hats, scarves and combs.”
99. During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches?
A) Wash hands thoroughly before and after client contact
B) Wear gloves when in contact with body secretions
C) Double glove when in contact with feces or vomitus
D) Wear gloves when disposing of contaminated linens The correct answer is A: Wash hands thoroughly before and after client contact
100. A nurse is reinforcing teaching with a client about compromised host precautions.
The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes?
A) grilled chicken sandwich and skim milk
B) roast beef, mashed potatoes, and green beans
C) peanut butter sandwich, banana, and iced tea
D) barbecue beef, baked beans, and cole slaw
The correct answer is B: roast beef, mashed potatoes, and green beans
101. After an explosion at a factory one of the workers approaches the nurse and says “I
am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks
should the nurse assign to this worker who wants to help during the care of the wounded workers?
A) Get temperatures
B) Take blood pressure
C) Palpate pulses
D) Check alertness
The correct answer is C: Palpate pulses
102. Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency?
A) An adolescent diagnosed with sepsis 7 days ago with vital signs maintained within low normal
B) A middle-aged woman documented to have had an uncomplicated myocardial infarction 4 days ago
C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis
D) A young adult in the second day of treatment for an overdose of acetometaphen
The correct answer is D: A young adult in the second day of treatment for an overdose of acetometaphen
103. The mother of a toddler who is being treated for pesticide poisoning asks: “Why is
activated charcoal used? What does it do?” What is the nurse’s best response?
A) ”Activated charcoal decreases the systemic absorption of the poison from the stomach."
B) ”The charcoal absorbs the poison and forms a compound that doesn’t hurt your child."
C) ”This substance helps to get the poison out of the body by the gastrointestinal system."
D) ”The action may bind or inactivate the toxins or irritants that are ingested by children or adults."
The correct answer is B: “The charcoal absorbs the poison and forms a compound that does’t hurt your child.”
104. The nurse is to administer a new medication to a client.
Which actions are in the best
interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say
A) ”Please state your name?" Upon entering the room the nurse should ask:
B) ”What is your name? What allergies do you have?" then check the client’s name band
and allergy band As the room is entered say
C) “What is your name?” then check the client’s name band Verify the client’s allergies on the admission sheet and order.
D) “Verify the client’s name on the name plate outside the room then as the nurse enters
the room ask the client “What is your first, middle and last name?” The correct answer is B: Upon entering the room the nurse should ask: “What is your
name? What allergies do you have?” then check the client'’s name band and allergy band
105. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition?
A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV)
B) A positive purified protein derivative with an abnormal chest x- ray
C) A tentative diagnosis of viral pneumonia with productive brown sputum
D) Advanced carcinoma of the lung with hemoptasis The correct answer is B: A positive purified protein derivative with an abnormal chest xray
106. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order
to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements?
A) In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice.
B) Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice.
C) Your family can use the same bathroom that you use without any special precautions.
D) Drink plenty of water and empty your bladder often during the initial 3 days of therapy.
The correct answer is A: “In the initial 48 hours avoid contact with children and pregnant
women, and after urination or defecation flush the commode twice.” 107. Which approach is the best way to prevent infections when providing care to clients in the home setting?
A) Hand washing before and after examination of clients
B) Wearing non powdered latex free gloves to examine the client
C) Using a barrier between the client’s furniture and the nurse’s bag
D) Wearing a mask with a shield during any eye/mouth/noseexamination The correct answer is A: Hand washing 108. A 10 year-old child has a history of epilepsy with tonic- clonic seizures. The school
nurse should instruct the classroom teacher that if the child experiences a seizure in the
classroom, the most important action during the seizure would be to
A) Move any chairs or desks at least 3 feet away from the child
B) Note the sequence of movements with the time lapse of the event
C) Provide privacy as much as possible to minimize fighting the other children
D) Place the hands or a folded blanket under the head of the child The correct answer is D: Place the hands or a folded blanket under the head of the child
109. A mother calls the hospital hot line and is connected to the triage nurse. The mother
proclaims: “I found my child with odd stuff coming from the mouth and an unmarked bottle nearby.” Which of these
comments would be the best for the nurse to ask the mother to determine if the child has swallowed a corrosive substance?
A) Ask the child if the mouth is burning or throat pain is present B) Take the child’s pulse at the wrist and see if the child is has trouble breathing lying flat.
C) What color is the child’s lips and nails and has the child voided today?
D) Has the child had vomiting or diarrhea or stomach cramps yet? The correct answer is A: “Ask the child if the mouth is burning or throat pain is present”
110. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement?
A) Have the client cough into a tissue and dispose in a separate bag
B) Instruct the client to cover the mouth with a tissue when coughing
C) Reinforce for all to wash their hands before and after entering the room
D) Place client in a negative pressure private room and have all who enter the room use masks with shields
The correct answer is D: Place client in a negative pressure private room and have all
who enter the room use masks with shields
111. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN?
A) Test a stool specimen for occult blood
B) Assist with the ambulation of a client with a chest tube
C) Irrigate and redress a leg wound
D) Admit a client from the emergency room
The correct answer is C: Irrigate and redress a leg wound 112. When assessing a client, it is important for the nurse to be informed about cultural
issues related to the client’s background because
A) Normal patterns of behavior may be labeled as deviant, immoral, or insane
B) The meaning of the client’s behavior can be derived from conventional wisdom
C) Personal values will guide the interaction between persons from 2 cultures
D) The nurse should rely on her knowledge of different developmental mental stages
The correct answer is A: Normal patterns of behavior may be labeled as deviant,
immoral, or insane
113. The nurse is responsible for several elderly clients, including a client on bed rest
with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
A) Assign an RN to provide total care of the client
B) Assign a nursing assistant to help the client with self-care activities
C) Delegate complete care to an unlicensed assistive personnel
D) Supervise a nursing assistant for skin care
The correct answer is D: Supervise a nursing assistant for skin care.
114. The nursing student is discussing with a preceptor the delegation of tasks to an
unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?
A) Assist a client post cerebral vascular accident to ambulate
B) Feed a 2 year-old in balanced skeletal traction
C) Care for a client with discharge orders
D) Collect a sputum specimen for acid fast bacillus
The correct answer is C: Care for a client with discharge orders 115. After working with a very demanding client, an unlicensed assistive personnel
(UAP) tells the nurse, “I have had it with that client. I just can’t do anything that pleases
him. I’m not going in there again.” The nurse should respond by saying
A) ”He has a lot of problems. You need to have patience with him."
B) ”I will talk with him and try to figure out what to do."
C) ”He is scared and taking it out on you. Let’s talk to figure out what to do."
D) ”Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day."
The correct answer is C: “He is scared and taking it out on you. Let'’s talk to figure out what to do.”
116. A client with a diagnosis of bipolar disorder has been referred to a local boarding
home for consideration for placement. The social worker telephoned the hospital unit for
information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements?
A) I am sorry. Referral information can only be provided by the client’s health care providers.
B) “I can never give any information out by telephone. How do I know who you are?"
C) Since this is a referral, I can give you the this information. D) I need to get the client’s written consent before I release any information to you.
The correct answer is D: I need to get the client’s written consent before I release any information to you.
117. A client is admitted with a diagnosis of schizophrenia. The client refuses to take
medication and states “I don’t think I need those medications. They make me too sleepy
and drowsy. I insist that you explain their use and side effects.” The nurse should understand that
A) A referral is needed to the psychiatrist who is to provide the client with answers
B) The client has a right to know about the prescribed medications C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications
D) Clients with schizophrenia are at a higher risk of psychosocial complications when
they know about their medication side effects
The correct answer is B: The client has a right to know about the prescribed medications
118. Which statement by the nurse is appropriate when asking an unlicensed assistive
personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
A) ”Have the client sit on the side of the bed for at least 2 minutes before helping him
stand."
B) ”If the client is dizzy on standing, ask him to take some deep breaths."
C) ”Assist the client to the bathroom at least twice on this shift."
D) ”After you assist him to the chair, let me know how he feels." The correct answer is A: “Have the client sit on the side of the bed for at least 2 minutes before helping him stand.”
119. The nurse receives a report on an older adult client with middle stage dementia.
What information suggests the nurse should do immediate follow up rather than delegate
care to the nursing assistant? The client
A) Has had a change in respiratory rate by an increase of 2 breaths
B) Has had a change in heart rate by an increase of 10 beats
C) Was minimally responsive to voice and touch
D) Has had a blood pressure change by a drop in 8 mmHg systolic The correct answer is C: Was minimally responsive to voice and touch
120. A client tells the nurse, “I have something very important to tell you if you promise
not to tell.” The best response by the nurse is A) ”I must document and report any information."
B) ”I can’t make such a promise."
C) ”That depends on what you tell me."
D) ”I must report everything to the treatment team." The correct answer is B: “I can’t make such a promise.”
121. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?
A) Be with a client who self-administers insulin
B) Cleanse and dress a small decubitus ulcer
C) Monitor a client’s response to passive range of motion exercises
D) Apply and care for a client’s rectal pouch
The correct answer is D: Apply and care for a client'’s rectal pouch 122. A client asks the nurse to call the police and states: “I need to report that I am being
abused by a nurse.” The nurse should first A) Focus on reality orientation to place and person
B) Assist with the report of the client’s complaint to the police
C) Obtain more details of the client’s claim of abuse
D) Document the statement on the client’s chart with a report to the manager
The correct answer is C: Obtain more details of the client’s claim of abuse
123. A nurse from the maternity unit is floated to the critical care unit because of staff
shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with
A) A Dopamine drip IV with vital signs monitored every 5 minutes
B) A myocardial infarction that is free from pain and dysrhythmias
C) A tracheotomy of 24 hours in some respiratory distress
D) A pacemaker inserted this morning with intermittent capture The correct answer is B: A myocardial infarction that is free from pain and dysrhythmias
124. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is
assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?
A) ”How long have you been a UAP and what units you have worked on?"
B) ”What type of care do you give on the surgical unit and what ages of clients?"
C) “What is your comfort level in caring for children and at what ages?"
D) ”Have you reviewed the list of expected skills you might need on this unit?"
The correct answer is D: “Have you reviewed the list of expected skills you might need on this unit?”
125. A client frequently admitted to the locked psychiatric unit repeatedly compliments
and invites one of the nurses to go out on a date. The nurse’s response should be to
A) Ask to not be assigned to this client or to work on another unit
B) Tell the client that such behavior is inappropriate
C) Inform the client that hospital policy prohibits staff to date clients D) Discuss the boundaries of the therapeutic relationship with the client The correct answer is D: Discuss the boundaries of the relationship with the client
126. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? A) To observe the type and amount of nasogastric tube drainage
B) Monitor the client for nausea or other complications
C) Irrigate the nasogastric tube with the ordered irrigate D) Perform nostril and mouth care
The correct answer is D: Perform nostril and mouth care 127. The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia.
Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?
A) Test blood sugar every 2 hours by accu check
B) Review with family and client signs of hyperglycemia
C) Monitor for mental status changes
D) Check skin condition of lower extremities
Review Information: The correct answer is A: Test blood sugar every 2 hours by accucheck
128. A nurse is working with one licensed practical nurse (PN), a student nurse and an
unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP?
A) A 76-year-old client with severe depression
B) A middle-aged client with an obsessive compulsive disorder
C) A adolescent with dehydration and anorexia
D) A young adult who is a heroin addict in withdrawal with hallucinations The correct answer is B: A middle-aged client with an obsessive compulsive disorder
129. The unlicensed assistive personnel (UAP) reports a sudden increase in temperature
to 101 degrees F for a post surgical client. The nurse checks on the client’s condition and
observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?
A) Encourage oral fluids for the temperature elevation
B) Check temperature 15 minutes after hot liquids are taken
C) Ask the client to drink only cold water and juices
D) Chart this temperature elevation on the flow sheet
The correct answer is B: Check temperature 15 minutes after hot liquids are taken
130. A client continuously calls out to the nursing staff when anyone passes the client’s
door and asks them to do something in the room. The best response by the charge nurse would be to
A) Keep the client’s room door cracked to minimize the distractions
B) Assign 1 of the nursing staff to visit the client regularly
C) Reassure the client that 1 staff person will check frequently if the client needs anything
D) Arrange for each staff member to go into the client’s room to check on needs every hour on the hour
The correct answer is B: Assign 1 of the nursing staff to visit the client regularly
131. A client with a new diagnosis of diabetes mellitus is referred for home care. A family
member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach?
A) The results of a standardized tool that measures depression
B) Observation of affect and behavior
C) Inquiry about use of alcohol
D) Family history of emotional problems or mental illness The correct answer is B: Observation of affect and behavior
132. A mother with a Roman Catholic belief has given birth in an ambulance on the way
to the hospital. The neonate is in very critical condition with little expectation of
surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do?
A) The refusal of any treatment for self and the neonate until she talks to a reader
B) The placement of a rosary necklace around the neonate’s neck and not to remove it unless absolutely necessary
C) Arrange for a church elder to be at the emergency department when the ambulance
arrives so a “laying on hands” can be done
D) Pour fluid over the forehead backwards towards the back of the head and say “I baptize you in the name of the father, the son and the holy spirit. Amen.” The correct answer is D: Pour fluid over the forehead backwards towards the back of the
head and say “I baptize you in the name of the father, the son and the holy spirit. Amen.”
133. An American Indian chief visits his newborn son and performs a traditional
ceremony that involves feathers and chanting. The attending nurse tells a colleague “I wonder if he has any idea how
ridiculous he looks – he’s a grown man!” The nurse’s response is an example of A) Discrimination
B) Stereotyping
C) Ethnocentrism
D) Prejudice
The correct answer is D: Prejudice
134. A client expresses anger when the call light is not answered within 5 minutes. The
client demanded a blanket. The best response for the nurse to make is
A) “I apologize for the delay. I was involved in an emergency.”
B) “Let’s talk. Why are you upset about this?”
C) “I am surprised that you are upset. The request could have waited a few more minutes.”
D) “I see this is frustrating for you. I have a few minutes so let’s talk.” The correct answer is D: “I see this is frustrating for you. I have a few minutes so let'’s talk.”
135. An elderly client who lives in a retirement community is admitted with these
behaviors as reported by the daughter: absence in the daily senior group activity, missing the weekly card games, a change in
calling the daughter from daily to once a week, and the client’s tomato garden is
overgrown with weeds. The nurse should assign this client to a room with which one of these clients?
A) An adolescent who was admitted the day before with acute situational depression
B) A middle aged person who has been on the unit for 72 hours with a dysthymia
C) An elderly person who was admitted 3 hours ago with cycothymia
D) A young adult who was admitted 24 hours ago for detoxification The correct answer is B: A middle aged person who has been on the unit for 72 hours with a dysthymia
136. A client diagnosed with anorexia nervosa states after lunch, “I shouldn’t have eaten
all of that sandwich, I don’t know why I ate it, I wasn’t hungry.” The client’s comments
indicate that the client is likely experiencing
A) Guilt
B) Bloating
C) Anxiety
D) Fear
The correct answer is A: Guilt
137. A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly
refuses pain medication because the client believes that suffering is part of life. The client
states “everyone’s life is in God’s hands.” The next action for the nurse to take is to
A) Report the situation to the health care provider
B) Discuss the situation with the client’s family
C) Ask the client if talking with a priest would be desired
D) Document the situation on the notes
The correct answer is C: Ask the client if talking with a priest would be desired
138. A teenage female is admitted with the diagnosis of anorexia nervosa. Upon
admission, the nurse finds a bottle of assorted pills in the client’s drawer.
The client tells
the nurse that they are antacids for stomach pains. The best response by the nurse would
be
A) “These pills aren’t antacids since they are all different.”
B) “Some teenagers use pills to lose weight.”
C) “Tell me about your week prior to being admitted.”
D) “Are you taking pills to change your weight?”
The correct answer is C: “Tell me about your week prior to being admitted.”
139. A client who has a belief based in Hinduism is nearing death. The nurse should plan for which action?
A) After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client’s wrist
B) The elders may be with the client during the process of the client dying and no last rites are given
C) The family must be with the client during the process of dying and be the only ones to wash the body after death
D) The body is ritually cleansed and burial is to be as soon as possible after the death
occurs
The correct answer is A: After death a Hindu priest will pour water into the mouth of the
client and tie a thread around the client'’s wrist
140. An explosion has occurred at a high school for children with special needs and
severe developmental delays. One of the students accompanied with a parent is seen at a
community health center a day later. After the initial assessment the nurse concludes that
the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next?
A) Help the student to identify a specific problem
B) Ask the parent to identify the major problem
C) Ask the student to think of different alternatives
D) Examine with the parent a variety of options
The correct answer is B: Ask the parent to identify the major problem
141. Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode?
A) “I think all children should have their heads shaved.”
B) “I have been restricted in thought and harmed.”
C) “I have powers to get you whatever you wish, no matter the cost.”
D) “I think all of my contacts last week have attempted to poison me.” Review Information: The correct answer is C: “I have powers to get you whatever you wish, no matter the cost.”
142. A client says, “It’s raining outside and it’s raining in my heart. Did you know that St.
Patrick drove the snakes out of Ireland? I’ve never been to
Ireland.” The nurse would document this behavior as
A) Perseveration
B) Circumstantiality
C) Neologisms
D) Flight of ideas
The correct answer is D: Flight of ideas
143. During the change-of-shift report the assigned nurse notes a
Catholic client is
scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice?
A) “I wonder who is paying for this trip to the hospital?”
B) “I think she needs to go to the city hospital.”
C) “All those people indulge in large families!”
D) “Doesn’t she know there’s such a thing as birth control?” The correct answer is D: “Doesn’t she know there'’s such a thing as birth control?”
144. Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?
A) ”You look upset. Would you like to talk about it?"
B) ”I’d like to know more about your family. Tell me about them." C) ”I understand that you lost your partner. I don’t think I could go on if that happened to
me."
D) ”You look very sad. How long have you been this way?" The correct answer is A: “You look upset. Would you like to talk about it?”
145. A nurse in the emergency department suspects domestic violence as the cause of a client’s injuries. What action should the nurse take first?
A) Ask client if there are any old injuries also present
B) Interview the client without the persons who came with the client
C) Gain client’s trust by not being hurried during the intake process
D) Photograph the specific injuries in question
The correct answer is B: Interview the client without the persons who came with the
client
146. Which of these findings would indicate that the nurse-client relationship has passed
from the orientation phase to the working phase? The client A) Has revitalized a relationship with her family to help cope with the death of a daughter
B) Had recognized regressive behavior as a defense mechanism
C) Expresses a desire to be cared for and pampered
D) Recognizes feelings with appropriate expression of feelings The correct answer is D: Recognizes feelings with appropriate expression of feelings
147. A client who is thought to be homeless is brought to the emergency department by
police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks in a loud tone of voice.
Which of these actions is the appropriate nursing intervention for the client at this time?
A) Allow the client to randomly move about the holding area until a hospital room is
available
B) Engage the client in an activity that requires focus and individual effort
C) Isolate the client in a secure room until control is regained by the client
D) Locate a room that has minimal stimulation outside of it for admission process
The correct answer is D: Locate a room that has minimal stimulation outside of it for admission process
148. A 2 day-old child with spina bifida and meningomyocele is in the intensive care unit
after the initial surgery. As the nurse accompanies the grandparents for a first visit, which
response should the nurse anticipate of the grandparents?
A) Depression
B) Anger
C) Frustration
D) Disbelief
The correct answer is D: Disbelief
149. Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence?
A) ”I am determined to leave my house in a week."
B) ”No one else in the family has been treated like this."
C) ”I have only been married for 2 months."
D) ”I have tried leaving, but have always gone back."
The correct answer is D: “I have tried leaving, but have always gone back.”
150. A nurse states: “I dislike caring for African-American clients because they are all so
hostile.” The nurse’s statement is an example of
A) Prejudice
B) Discrimination
C) Stereotyping
D) Racism
The correct answer is C: Stereotyping
151. Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct?
A) “It is to observe reactive service and product problem solving." B) Improvement of the processes in a proactive, preventive mode is paramount.
C) A chart audits to finds common errors in practice and outcomes associated with goals.
D) A flow chart to organize daily tasks is critical to the initial stages. The correct answer is B: Improvement of the processes in a proactive, preventive mode is paramount.
152. The nurse manager informs the nursing staff at morning report that the clinical nurse
specialist will be conducting a research study on staff attitudes toward client care. All
staff are invited to participate in the study if they wish. This affirms the ethical principle of
A) Anonymity
B) Beneficence
C) Justice
D) Autonomy
The correct answer is D: Autonomy
153. When teaching a client about the side effects of fluoxetine
(Prozac), which of the following will be included?
A) Tachycardia blurred vision, hypotension, anorexia
B) Orthostatic hypotension, vertigo, reactions to tyramine rich foods
C) Diarrhea, dry mouth, weight loss, reduced libido
D) Photosensitivity, seizures, edema, hyperglycemia
The correct answer is C: Diarrhea, dry mouth, weight loss, reduced libido
154. The nurse is performing an assessment of the motor
function in a client with a head injury. The best technique is
A) A firm touch to the trapezius muscle or arm
B) Pinching any body part
C) Sternal rub
D) Gentle pressure on eye orbit
The correct answer is D: Gentle pressure on eye orbit
155. The nurse is teaching about non steroidal anti-inflammatory drugs to a group of
arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions?
A) Reporting joint stiffness in the morning
B) Taking the medication 1 hour before or 2 hours after meals
C) Using alcohol in moderation unless driving
D) Continuing to take aspirin for short term relief
The correct answer is B: Taking the medication 1 hour before or 2 hours after meals
156. A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of
the medication. The client should be instructed to immediately report which of these?
A) Double vision and visual halos
B) Extremity tingling and numbness
C) Confusion and lightheadedness
D) Sensitivity of sunlight
The correct answer is B: Extremity tingling and numbness
157. The nurse admits a 2 year-old child who has had a seizure.
Which of the following
statement by the child’s parent would be important in determining the etiology of the seizure?
A) “He has been taking long naps for a week.”
B) “He has had an ear infection for the past 2 days.”
C) “He has been eating more red meat lately.”
D) “He seems to be going to the bathroom more frequently.”
The correct answer is B: “He has had an ear infection for the past 2 days.”
158. A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter. The
catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority?
A) Check that the catheter tip is intact
B) Apply a pressure dressing to the site
C) Monitor respiratory status
D) Assess for mental status changes
The correct answer is B: Apply a pressure dressing to the site
159. An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant
in the near future. When the nurse obtains the child’s health history, the mother indicates
that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understands
that which of the following is true in regards to giving immunizations to this child?
A) Live vaccines are withheld in children with renal chronic illness
B) The MMR vaccine should be given now, prior to the transplant
C) An inactivated form of the vaccine can be given at any time
D) The risk of vaccine side effects precludes giving the vaccine The correct answer is B: The MMR vaccine should be given now, prior to the transplant
160. The nurse is preparing to administer a tube feeding to a post- operative client. To
accurately assess for a gastrostomy tube placement, the priority is to
A) Auscultate the abdomen while instilling 10 cc of air into the tube
B) Place the end of the tube in water to check for air bubbles
C) Retract the tube several inches to check for resistance
D) Measure the length of tubing from nose to epigastrium The correct answer is A: Auscultate the abdomen while instilling 10 cc of air into the tube
