152. A child is sent to the school nurse by a teacher who has a written note that Fifth’s disease is suspected. Which characteristic would the nurse expect to find?

A)  Macule that rapidly progresses to papule and then vesicles

B)  Erythema on the face, primarily on cheeks giving a “slapped face” appearance C) Discrete rose pink macules will appear first on the trunk and fade when pressure is applied

D) Kopeck spots appear first followed by a rash that appears first on the face and spreads downward

The correct answer is B: Erythema on the face, primarily on cheeks giving a “slapped face” appearance

 

 

153. Delirium tremens could best be described as

A)  Disorganized thinking, feelings of terror and non-purposeful behavior

B)  A generalized shaking of the body accompanied by repetitive thoughts

C)  An excited state accompanied by disorientation, hallucination and tachycardia

D)  Single or multiple jerks caused by rapid contracting muscles

The correct answer is C: An excited state accompanied by disorientation, hallucination and tachycardia

 

 

154. An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

A)  “Have you had a recent heart attack?”

B)  “Do you become short of breath during your normal dailyactivities?”

C)  “How many pillows do you use at night to sleep comfortably?”

D)  “Do you smoke?”

The correct answer is B: “Do you become short of breath during your normal daily activities?”

 

 

155. The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem? A) Chronic vessel plaque formation

B)  Pulmonary embolism

C)  Occlusions at the vessel bifurcations

D)  Coronary artery aneurysms

The correct answer is D: Coronary artery aneurysms

 

156. The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which finding is most likely to occur?

A)  Chest pain

B)  Peripheral edema

C)  Nail clubbing

D)  Lethargy

The correct answer is B: Peripheral edema

 

 

157. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other

behavior?

A)  Sexual promiscuity

B)  Poor body image

C)  Dropping out of school

D)  Drug experimentation

The correct answer is B: Poor body image

 

 

158. The nurse should initiate discharge planning for a client

A)  When the client or family demonstrate readiness to learn self care modalities

B)  When informed that a date for discharge has been determined

C)  Upon admission to the emergency room

D)  When the client’s condition is stabilized on the assigned unit

The correct answer is C: Upon admission to the emergency room

 

 

159. The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client? A) Protection for the granulation tissue

B)  Heal infection

C)  Decried eschar

D)  Keep the tissue intact

The correct answer is D: Keep the tissue intact

 

 

160. When providing nursing measures to relieve a 102-degree Fahrenheit fever in a

 

toddler with an infection, what is the most effective intervention? A) Use medications to lower the temperature set point B) Apply extra layers of clothing to prevent shivering

C)  Immerse the child in a tub containing cool water

D)  Give a tepid sponge bath prior to giving an antipyretic

The correct answer is A: Use medications to lower the temperature set point

 

 

2018 HESI EXIT V4

 

1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child?

A)  Make certain the child is maintained in correct body alignment.

B)  Be sure the traction weights touch the end of the bed.

C)  Adjust the head and foot of the bed for the child’s comfort

D)  Release the traction for 15-20 minutes every 6 hours PRN.

The correct answer is A: Make certain the child is maintained in correct body alignment.

 

 

2. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider? A) Height and weight percentiles vary widely

B)  Growth pattern appears to have slowed

C)  Recumbent and standing height are different

D)  Short term weight changes are uneven

The correct answer is A: Height and weight percentiles vary widely

 

 

3. The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?

A)  Teach the parents how to perform cardiopulmonary resuscitation

B)  Recommend that the parents give in when he holds his breath to prevent anoxia

C)  Advise the parents to ignore breath holding because breathing will begin as a reflex D) Instruct the parents on how to reason with the child about possible harmful effects The correct answer is C: Advise the parents to ignore breath holding because breathing will begin as a reflex

 

 

4. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina?

A)  “My pain is deep in my chest behind my sternum.”

B)  “When I sit up the pain gets worse.”

C)  “As I take a deep breath the pain gets worse.”

D)  “The pain is right here in my stomach area.”

 

The correct answer is A: “My pain is deep in my chest behind my sternum.”

.

 

5. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client’s recent

memory?

A) “Name the year.” “What season is this?” (pause for answer after each question) B) “Subtract 7 from 100 and then subtract 7 from that.” (pause for answer) “Now continue to subtract 7 from the new number.”

C)     “I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen.”

D)    “What is this on my wrist?” (point to your watch) Then ask, “What is the purpose of it?”

The correct answer is C: “I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen.”

 

 

6. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?

A)  Food

B)  Warmth C) Security

D) Comfort

The correct answer is C: Security

 

 

7. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?

A) “I cannot give this medication as it is written. I have no idea of what you mean.” B) “Would you please clarify what you have written so I am sure I am reading it correctly?”

C)     “I am having difficulty reading your handwriting. It would save me time if you would be more careful.”

D)    “Please print in the future so I do not have to spend extra time attempting to read your writing.”

The correct answer is B) “Would you please clarify what you have written so I am sure I am

reading it correctly?”

 

8. What is the most important consideration when teaching parents how to reduce risks in the home?

A) Age and knowledge level of the parents

B)  Proximity to emergency services

C)  Number of children in the home D) Age of children in the home

The correct answer is D: Age of children in the home

 

 

9. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the

nurse enters the room to request something for pain. The nurse should A) Administer a placebo

B)  Encourage increased fluid intake

C)  Administer the prescribed analgesia

D)  Recommend relaxation exercises for pain control

The correct answer is C: Administer the prescribed analgesia

 

 

10. While caring for a toddler with croup, which initial sign of croup requires the nurse’s immediate attention? A) Respiratory rate of 42

B)  Lethargy for the past hour

C)  Apical pulse of 54

D)  Coughing up copious secretions

The correct answer is A: Respiratory rate of 30

 

 

11. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings?

A)  Lethargy

B)  Heat intolerance

C)  Diarrhea

D)  Skin eruptions

The correct answer is A: Lethargy

 

 

12. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse?

A)  “Do not worry. Epilepsy can be treated with medications.”

B)  “The seizure may or may not mean your child has epilepsy.”

C)  “Since this was the first convulsion, it may not happen again.” D) “Long term treatment will prevent future seizures.”

The correct answer is B: “The seizure may or may not mean your child has epilepsy.”

 

 

13. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies?

A)  Risk for injury

B)  Risk for knowledge deficit

C)  Altered thought process

D)  Disturbance in self-esteem

The correct answer is A: Risk for injury

 

 

14. The nurse is caring for a 10 month-old infant who is has oxygen via mask. It is important for the nurse to maintain patency of which of these areas?

A)  Mouth

B)  Nasal passages

C)  Back of throat

D)  Bronchials

The correct answer is B: Nasal passages

 

 

15. The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client? A) “Take at least 2 weeks off from work.”

B)  “You will need another chest x-ray in 6 weeks.”

C)  “Take your temperature every day.”

D)  “Complete all of the antibiotic even if your findings decrease.”

The correct answer is D: “Complete all of the antibiotic even if your findings decrease.”

 

16. When counseling a 6 year old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder? A) Has no clear etiology

B)  May be associated with sleep phobia

C)  Has a definite genetic link

D)  Is a sign of willful misbehavior

The correct answer is A: Has no clear etiology

 

 

17. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?

A)  Reprimand the child and give a 15 minute “time out”

B)  Maintain a permissive attitude for this behavior

C)  Use patience and a sense of humor to deal with this behavior D) Assert authority over the child through limit setting

The correct answer is C: Use patience and a sense of humor to deal with this behavior

 

18. The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse?

A)  Chewable aspirin is the preferred analgesic

B)  Topical cortisone ointment relieves itching

C)  Papules, vesicles, and crusts will be present at one time D) The illness is only contagious prior to lesion eruption

The correct answer is C: Papules, vesicles, and crusts will be present at one time

 

19. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally.

Which nursing intervention should be performed first?

A)  Take the client’s vital signs

B)  Place the client in a sitting position with legs dangling

C)  Contact the health care provider

D)  Administer the PRN anti anxiety agent

The correct answer is B: Place the client in a sitting position with legs dangling

 

 

20. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to

A)  Dress the child warmly to avoid chilling

B)  Keep the child away from other children for the duration of the rash

C)  Clean the affected areas with tepid water and detergent

D)  Wrap the child’s hand in mittens or socks to prevent scratching

The correct answer is D: Wrap the child'’s hand in mittens or socks to prevent scratching

 

 

21. A recovering alcoholic asked the nurse, “Will it be ok for me to just drink at special family gatherings?” Which initial response by the nurse would be best?

A)    “A recovering person has to be very careful not to lose control, therefore, confine your drinking just at family gatherings.”

B)     “At your next AA meeting discuss the possibility of limited drinking with your sponsor.”

C)     “A recovering person needs to get in touch with their feelings. Do you want a drink?” D) “A recovering person cannot return to drinking without starting the addiction process over.”

The correct answer is D: “The recovering person cannot return to drinking without starting the addiction process over.”

 

 

22. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?

A)  Age 40 years

B)  Lactose intolerance

C)  Family history of breast cancer

D)  Uses cocaine on weekends

The correct answer is D: Uses cocaine on weekends

 

 

23. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication? A) Potassium

B)  Arterial blood gasses

C)  Blood urea nitrogen

D)  Thiocyanate

The correct answer is D: Thiocyanate

 

 

24. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?

A)  With acceptance and views the victim’s comment as an indication that their marriage is in trouble

B)  With fear of rejection causing increased rage toward the victim

C)  With a new commitment to seek counseling to assist with their marital problems

D)  With relief, and welcomes the separation as a means to have some personal time

The correct answer is B: With fear of rejection causing increased rage toward the victim

 

25. A postpartum mother is unwilling to allow the father to participate in the newborn’s care, although he is interested in doing so. She states, “I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers.” The nurse’s initial intervention should be what focus?

A)  Discuss with the mother sharing parenting responsibilities

B)  Set time aside to get the mother to express her feelings and concerns

C)  Arrange for the parents to attend infant care classes D) Talk with the father and help him accept the wife’s decision

The correct answer is B: Set time aside to get the mother to express her feelings and concerns

 

 

26. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client

A)  Eat foods high in sodium increases sputum liquefaction

B)  Use oxygen during meals improves gas exchange

C)  Perform exercise after respiratory therapy enhances appetite

D)  Cleanse the mouth of dried secretions reduces risk of infection

The correct answer is B: Use oxygen during meals improves gas exchange

 

 

27. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?

A)  I noticed a little lump a little above the belly button.

B)  The baby seems hungry all the time.

C)  Mild vomiting that progressed to vomiting shooting across the room.

D)  Irritation and spitting up immediately after feedings.

The correct answer is C: Mild emesis progressing to projectile vomiting

 

 

28. The nurse is assessing a child for clinical manifestations of iron deficiency anemia.

Which factor would the nurse recognize as cause for the findings? A) Decreased cardiac output

B) Tissue hypoxia C) Cerebral edema

D) Reduced oxygen saturation

The correct answer is B: Tissue hypoxia

 

 

29. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet

A)  High in carbohydrates and proteins

B)  Low in carbohydrates and proteins

C)  High in carbohydrates, low in proteins

D)  Low in carbohydrates, high in proteins

The correct answer is A: High in carbohydrates and proteins

 

 

30. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?

A)  Increased 10% in height

B)  2 deciduous teeth

C)  Tripled the birth weight

D)  Head > chest circumference

The correct answer is C: Tripled the birth weight

 

 

31. A Hispanic client in the postpartum period refuses the hospital food because it is “cold.” The best initial action by the nurse is to

A)  Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes

B)  Ask the client what foods are acceptable or bad

C)  Encourage her to eat for healing and strength

D)  Schedule the dietitian to meet with the client as soon as possible The correct answer is B: Ask the client what foods are acceptable

 

 

32. The father of an 8 month-old infant asks the nurse if his infant’s vocalizations are normal for his age. Which of the following would the nurse expect at this age?

A)  Cooing

B)  Imitation of sounds

C)  Throaty sounds D) Laughter

The correct answer is B: Imitation of Sounds

 

 

33. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? A) Seizures

B)  Withdrawal

C)  Craving

D)  Marked tolerance

The correct answer is B: Withdrawal

 

 

34. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by

A)  Seeking medical help for the victim’s injuries

B)  Minimizing the episode and underestimating the victim’s injuries

C)  Contacting a close friend and asking for help

D)  Being very remorseful and assisting the victim with medical care

The correct answer is B: Minimizing the episode and underestimating the victim’s injuries

 

 

35. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?

A) “Do you want to take this pretty red medicine?” B) “You will feel better if you take your medicine.”

C)  “This is your medicine, and you must take it all right now.”

D)  “Would you like to take your medicine from a spoon or a cup?”

The correct answer is D: “Would you like to take your medicine from a spoon or a cup?”

 

 

36. In planning care for a child diagnosed with minimal change nephrotic syndrome, the

nurse should understand the relationship between edema formation and A) Increased retention of albumin in the vascular system

B)  Decreased colloidal osmotic pressure in the capillaries

C)  Fluid shift from interstitial spaces into the vascular space

D)  Reduced tubular reabsorption of sodium and water

The correct answer is B: Decreased colloidal osmotic pressure in the capillaries

 

 

37. An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these

initial findings, the nurse would assess the child for additional findings of

A)  Septicemia

B)  Dehydration

C)  Hypokalemia

D)  Hypercalcemia

The correct answer is B: Dehydration

 

38. A client who has been drinking for five years states that he drinks when he gets upset about “things” such as being unemployed or feeling like life is not leading anywhere. The

nurse understands that the client is using alcohol as a way to deal with A) Recreational and social needs

B)  Feelings of anger

C)  Life’s stressors

D)  Issues of guilt and disappointment

The correct answer is C: Life’s stressors

 

 

39. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15

A.M. What is the frequency of the contractions?

A)  14 minutes

B)  10 minutes

C)  15 minutes

D)  Nine minutes

The correct answer is C: 15 minutes

 

 

40. The nurse is performing an assessment on a child with severe airway obstruction.

Which finding would the nurse anticipate finding?

A)  Retractions in the intercostal tissues of the thorax

B)  Chest pain aggravated by respiratory movement

C)  Cyanosis and mottling of the skin

D)  Rapid, shallow respirations

The correct answer is A: Retractions in the soft tissues of the thorax

 

 

41. During the evaluation phase for a client, the nurse should focus on

A) All finding of physical and psychosocial stressors of the client and in the family B) The client’s status, progress toward goal achievement, and ongoing re-evaluation

C) Setting short and long-term goals to insure continuity of care from hospital to home D) Select interventions that are measurable and achievable within selected timeframes The correct answer is B: The client'’s status, progress toward goal achievement, and ongoing re evaluation

 

 

42. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should

A)  Observe the child’s behavior on at least 2 occasions

B)  Consult with the teacher about how to control impulsivity

C)  Compile a history of behavior patterns and developmental accomplishments

D)  Compare the child’s behavior with classic signs and symptoms

The correct answer is C: Compile a history of behavior patterns and developmental accomplishments

 

 

43. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of

care?

A)  Measure head circumference

B)  Place in airborne isolation

C)  Provide passive range of motion

D)  Provide an over-the-crib protective top

The correct answer is A: Measure head circumference

 

 

44. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?

A)  Blood urea nitrogen

B)  Acid phosphatase

C)  Bilirubin

D)  Sedimentation rate

The correct answer is C: Bilirubin

 

 

45. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?

A)  May drink as much milk as desired

B)  Can have milk mixed with other foods

C)  Will benefit from fat-free cow’s milk

D)  Should be limited to 3-4 cups of milk daily

The correct answer is D: Should be limited to three to four cups of milk daily

 

 

46. The nurse is talking with a client. The client abruptly says to the nurse, “The moon is full. Astronauts walk on the moon. Walking is a good health habit.” The client’s behavior most likely indicates A) Neologisms B) Dissociation

* C) Flight of ideas

D) Word salad

The correct answer is C: Flight of ideas

 

 

47. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?

A)  Jumping rope

B)  Tying shoelaces C) Riding a tricycle

D) Playing hopscotch

The correct answer is C: Riding a tricycle

 

 

48. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is

A)  A transparent film dressing

B)  Wet dressing with debridement granules

C)  Wet to dry with hydrogen peroxide

D)  Moist saline dressing

The correct answer is D: Moist saline dressing

49. The nurse enters a 2 year-old child’s hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, “No!”. What would be the

most appropriate next action?

A)  Leave the room and return five minutes later and give the medicine

B)  Explain to the child that the medicine must be taken now

C)  Give the medication to the father and ask him to give it

D)  Mix the medication with ice cream or applesauce

The correct answer is A: Leave the room and return five minutes later and give the medicine

 

 

50. A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?

A)  “I understand that a glass of wine with dinner is healthy.”

B)  “Beer is not really hard alcohol, so I guess I can drink some.”

C)  “If I drink, my baby may be harmed before I know I am pregnant.” D) “Drinking with meals reduces the effects of alcohol.”

The correct answer is C: “If I drink, my baby may be harmed before I know I am pregnant.”

 

 

51. The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should A) Review the medications the client is receiving

B)  Increase the formula infusion rate

C)  Increase the amount of water used to flush the tube D) Attach a rectal bag to protect the skin

The correct answer is A: Review the medications the client is receiving

 

 

52. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated?

A)  “My partner’s breathing rate is usually below 12.”

B)  “I find the mood swings and the change from a calm person to being angry all the time hard to deal with.”

C)  “It seems our sex life is non existant over the past 6 months.”

D)  “In the morning and evening I hear complaints that reading is next to impossible from blurred print.”

The correct answer is B: “I find the mood swings and the change from a calm person to

being angry all the time hard to deal with.”

 

53. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver? A) It measures a child’s intelligence.

B)  It assesses a child’s development.

C)  It evaluates psychological responses.

D)  It helps to determine problems.

The correct answer is B: It assesses a child'’s development.

 

 

54. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy.

The parents are anxious and concerned about the child’s reaction to impending surgery. Which nursing intervention would be best to prepare the child?

A)  Introduce the child to all staff the day before surgery

B)  Explain the surgery 1 week prior to the procedure

C)  Arrange a tour of the operating and recovery rooms

D)  Encourage the child to bring a favorite toy to the hospital

The correct answer is B: Explain the surgery 1 week prior to the procedure

 

 

55. The nurse, assisting in applying a cast to a client with a broken arm, knows that A) The cast material should be dipped several times into the warm water

B)  The cast should be covered until it dries

C)  The wet cast should be handled with the palms of hands D) The casted extremity should be placed on a cloth-covered surface

The correct answer is C: The wet cast should be handled with the palms of hands

 

 

56. Based on principles of teaching and learning, what is the best initial approach to pre- op teaching for a client scheduled for coronary artery bypass? A) Touring the coronary intensive unit

B)  Mailing a video tape to the home

C)  Assessing the client’s learning style

D) Administering a written pre-test

The correct answer is C: Assessing the client'’s learning style

 

 

57. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer

communicable, what should the nurse assess for in this child? A) All lesions crusted

B)  Elevated temperature

C)  Rhinorrhea and coryza

D)  Presence of vesicles

The correct answer is A: All lesions crusted

 

 

58. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?

A) “I should position my baby completely facing me with my baby’s mouth in front of my nipple.”

B)  “The baby should latch onto the nipple and areola areas.”

C)  “There may be times that I will need to manually express milk.” D) I can switch to a bottle if I need to take a break from breast feeding.

The correct answer is D: I can switch to a bottle if I need to take a break from breast feeding.

 

 

59. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit

for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?

A)  Stressors in the home

B)  Medication compliance

C)  Exposure to hot temperatures D) Alcohol use

The correct answer is B: Medication compliance

 

 

60. The nurse is caring for a client with an unstable spinal cord injury at the T7 level.

Which intervention should take priority in planning care? A) Increase fluid intake to prevent dehydration

B)  Place client on a pressure reducing support surface

C)  Use skin care products designed for use with incontinence

D)  Increase caloric intake to aid healing

The correct answer is B: Place client on a pressure reducing support surface

 

61. A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning? A) 9 month-old who stays with a sitter 5 days a week

B)  20 month-old who has just learned to climb stairs

C)  10 year-old who occasionally stays at home unattended

D)  15 year-old who likes to repair bicycles

The correct answer is B: Twenty month-old who has just learned to climb stairs

 

62. During an examination of a 2 year-old child with a tentative diagnosis of Wilm’s tumor, the nurse would be most concerned about which statement by the mother? A) My child has lost 3 pounds in the last month.

B)  Urinary output seemed to be less over the past 2 days.

C)  All the pants have become tight around the waist.

D)  The child prefers some salty foods more than others.

The correct answer is C: Clothing has become tight around the waist

 

 

63. What is the most important aspect to include when developing a home care plan for a client with severe arthritis?

A)  Maintaining and preserving function

B)  Anticipating side effects of therapy

C)  Supporting coping with limitations

D)  Ensuring compliance with medications

The correct answer is A: Maintaining and preserving function

 

 

64. A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent? A) Age of the child

B)  Sibling position in family

C)  Stressful family events

D)  Parental discipline strategies

The correct answer is A: Age of the child

 

 

65. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants? A) Contains less lactose

B)  Is higher in calories/ounce

C)  Provides antibodies

D)  Has less fatty acid

The correct answer is C: Provides antibodies

 

 

66. Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects?

A)  Red reflex test

B)  Visual acuity

C)  Pupil response to light D) Cover test

The correct answer is A: Red reflex test

 

 

67. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?

A)  Transparent dressing

B)  Dry sterile dressing with antibiotic ointment

C)  Wet to dry dressing

D)  Occlusive moist dressing

The correct answer is D: Occlusive moist dressing

 

 

68. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? A) Cartoon stickers

B)  Large wooden puzzle

C)  Blunt scissors and paper

D)  Beach ball

The correct answer is B: Large wooden puzzle

 

 

69. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the

A)  Yang, the positive force that represents light, warmth, and fullness

B)  Yin, the negative force that represents darkness, cold, and emptiness

C)  Use of improper hot foods, herbs and plants

D)  A failure to keep life in balance with nature and others

The correct answer is B: Yin, the negative force that represents darkness, cold, and emptiness

 

 

70. A 2 year-old child has just been diagnosed with cystic fibrosis. The child’s father asks the nurse “What is our major concern now, and what will we have to deal with in the future?” Which of the following is the best response? A) “There is a probability of life-long complications.”

B)  “Cystic fibrosis results in nutritional concerns that can be dealt with.”

C)  “Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis.” D) “You will work with a team of experts and also have access to a support group that the family can attend.”

The correct answer is C: “Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis.”

 

 

71. Which type of accidental poisoning would the nurse expect to occur in children under age 6?

A)  Oral ingestion

B)  Topical contact

C)  Inhalation

D)  Eye splashes

The correct answer is A: Oral ingestion

 

 

72. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands

constant attention from the staff. Which activity would be best for the client?

A)  Reading

B)  Checkers

C)  Cards

D)  Ping-pong

The correct answer is D: Ping-pong

 

73. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? A) Widening pulse pressure

B)  Pleural friction rub

C)  Distended neck veins

D)  Bradycardia

The correct answer is C: Distended neck veins

 

 

74. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?

A)  Assess for generalized edema

B)  Monitor for increased urinary output

C)  Encourage rest during hyperactive periods

D)  Note patterns of increased blood pressure

The correct answer is D: Note patterns of increased blood pressure

 

 

75. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? A) Schedule the therapy thirty minutes after meals

B)  Teach the child not to cough during the treatment

C)  Confine the percussion to the rib cage area

D)  Place the child in a prone position for the therapy

The correct answer is C: Confine the percussion to the rib cage area

 

76. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to “see old buddies.” The nurse understands that the client’s behavior is a warning sign to indicate that the client may be

A)  headed for relapse

B)  feeling hopeless

C)  approaching recovery

D)  in need of increased socialization

The correct answer is A: headed for relapse

 

 

77. A client was admitted to the psychiatric unit with major depression after a suicide

attempt. In addition to feeling sad and hopeless, the nurse would assess for

A)  Anxiety, unconscious anger, and hostility

B)  Guilt, indecisiveness, poor self-concept

C)  Psychomotor retardation or agitation

D)  Meticulous attention to grooming and hygiene

The correct answer is C: Psychomotor retardation or agitation

 

 

78. A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client?

A) “No, it would be best if you brought the client some reading material that she could read at night.”

B)  “No, your presence may cause the client to become more anxious.”

C)  “Yes, staying with the client and orienting her to her surroundings may decrease her anxiety.”

D) “Yes, would you like to spend the night when the client’s behavior indicates that she is frightened?”

The correct answer is C: “Yes, staying with the client and orienting her to her surroundings may decrease her anxiety.”

 

79. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform? A) Say 2 words

B)  Pull up to stand

C)  Sit without support

D)  Drink from a cup

The correct answer is C: Sit without support

 

80. The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group?

A)  Bulimia

B)  Anorexia

* C) Obesity

D) Malnutrition

The correct answer is C: Obesity

 

 

81. At the geriatric day care program a client is crying and repeating “I want to go home. Call my daddy to come for me.” The nurse should

A)  Invite the client to join the exercise group

B)  Tell the client you will call someone to come for her

C)  Give the client simple information about what she will be doing

D)  Firmly direct the client to her assigned group activity The correct answer is C: Give the client simple information about what she will be doing

 

 

82. A victim of domestic violence states to the nurse, “If only I could change and be how my companion wants me to be, I know things would be different.” Which would be the best response by the nurse?

A) “The violence is temporarily caused by unusual circumstances, don’t stop hoping for a change.”

B)  “Perhaps, if you understood the need to abuse, you could stop the violence.”

C)  “No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?”

D) “Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do.”

The correct answer is D: “Batterers lose self control because of their own internal

reasons, not because of what their partner did or did not do.”

 

 

83. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn’t really like having to use

her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation? A) Degeneration of the alveoli

B)  Chronic broncho constriction of the large airways

C)  Lung remodeling and permanent changes in lung function D) Frequent pneumonia

The correct answer is C: Lung remodeling and permanent changes in lung function

 

 

84. A mother wants to switch her 9 month-old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?

A)  Change the baby to whole milk

B)  Add chocolate syrup to the bottle

C)  Continue with the present formula

D)  Offer fruit juice frequently

The correct answer is C: Continue with the present formula

 

 

85. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice? A) When a family member offers information about their loved one

B)  When the client threatens self-harm and harm to others

C)  When the health care provider decides the family has a right to know the client’s diagnosis

D)  When a visitor insists that the visitor has been given permission by the client

The correct answer is B: When the client threatens self-harm and harm to others

 

 

86. The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?

A)  Monitor for hyperkalemia

B)  Place in protective isolation

C)  Precautions with position changes

D)  Administer diuretics as ordered

The correct answer is C: Precautions with position changes

 

 

87. The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without

difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?

A) Activity intolerance caused by fatigue related to chronic tissue hypoxia

B)  Impaired mobility related to chronic obstructive pulmonary disease C) Self care deficit caused by fatigue related to dyspnea

D) Ineffective airway clearance related to increased bronchial secretions

The correct answer is A: Activity intolerance caused by fatigue related to chronic tissue hypoxia

 

 

88. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure? A) Standing and sitting

B)  In both arms

C)  After exercising

D)  Supine position

The correct answer is B: In both arms

 

 

89. The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group? A) Aerobic exercise classes

B)  Transportation for shopping trips

C)  Reminiscence groups

D)  Regularly scheduled social activities

The correct answer is C: Reminiscence groups

 

 

90. Post-procedure nursing interventions for electroconvulsive therapy include

A) Applying hard restraints if seizure occurs B) Expecting client to sleep for 4 to 6 hours

C)  Remaining with client until oriented

D)  Expecting long-term memory loss

The correct answer is C: Remaining with client until oriented

 

91. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?

A)  Stand on 1 foot

B)  Catch a ball

C)  Skip on alternate feet

D)  Ride a bicycle

The correct answer is A: Stand on 1 foot

.  

92. The mother of a 15 month-old child asks the nurse to explain her child’s lab results and how they show her child has iron deficiency anemia. The nurse’s best response is A) “Although the results are here, your doctor will explain them later.”

B)  “Your child has less red blood cells that carry oxygen.”

C)  “The blood cells that carry nutrients to the cells are too large.” D) “There are not enough blood cells in your child’s circulation.”

The correct answer is B: “Your child has less red blood cells that carry oxygen.”

 

 

93. In a child with suspected coarctation of the aorta, the nurse would expect to find A) Strong pedal pulses

B)  Diminishing carotid pulses

C)  Normal femoral pulses

D)  Bounding pulses in the arms

The correct answer is D: Bounding pulses in the arms

 

 

94. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client’s behavior most likely indicates

A)  Feelings of increasing anxiety related to paranoia

B)  Social isolation related to altered thought processes

C)  Sensory perceptual alteration related to withdrawal from environment D) Impaired verbal communication related to impaired judgment

The correct answer is B: Social isolation related to altered thought processes

 

 

95. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0- to-10 scale. The client refuses all pain medication other than Motrin, which does not

relieve his pain. The next action for the nurse to take is to A) Ask the client about the refusal of certain pain medications

B) Talk with the client’s family about the situation C) Report the situation to the health care provider D) Document the situation in the notes

The correct answer is A: Ask the client about the refusal of certain pain medications

 

 

96. When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection?

A)  Gonorrhea

B)  Chlamydia

C)  Herpes

D)  HIV

The correct answer is B: Chlamydia

 

 

97. First-time parents bring their 5 day-old infant to the pediatrician’s office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds

are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings?

A)  The pediatrician must examine the baby

B)  Emergency equipment should be available

C)  This breathing pattern is normal

D)  A future referral may be indicated

The correct answer is C: This breathing pattern is normal

 

98. A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect in assessing this client?

A)  Hyperextension of the neck with passive shoulder flexion

B)  Flexion of the hip and knees with passive flexion of the neck

C)  Flexion of the legs with rebound tenderness

D)  Hyper flexion of the neck with rebound flexion of the legs

The correct answer is B: Flexion of the hip and knees with passive flexion of the neck

 

 

99. Clients taking which of the following drugs are at risk for depression? A) Steroids

B)  Diuretics

C)  Folic acid

D) Aspirin

The correct answer is A: Steroids

  

100. When a client is having a general tonic clonic seizure, the nurse should A) Hold the client’s arms at their side

B)  Place the client on their side

C)  Insert a padded tongue blade in client’s mouth D) Elevate the head of the bed

The correct answer is B: Place the client on their side

 

 

101 After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, “My husband told me to get treatment or he would divorce me. I don’t believe I really need treatment but I don’t want my husband to leave me.” Which response by the nurse would assist the client?

A)    “In early recovery, it’s quite common to have mixed feelings, but unmotivated people can’t get well.”

B)     “In early recovery, it’s quite common to have mixed feelings, but I didn’t know you had been pressured to come.”

C)     “In early recovery it’s quite common to have mixed feelings, perhaps it would be best to seek treatment on an out client bases.”

D)    “In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you.”

The correct answer is D: “In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you.”

 

 

102. A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passes loose, watery stool. Which of these is a nursing priority?

A)  Hold the infant at frequent intervals.

B)  Assess for neonatal withdrawal syndrome

C)  Offer fluids to prevent dehydration

D)  Administer paregoric to stop diarrhea

The correct answer is B: Assess for neonatal withdrawal syndrome

 

 

103. The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to

A)  Dehydration

B)  Diminished blood volume

C)  Decreased cardiac output

D)  Renal failure

The correct answer is C: Decreased cardiac output

 

 

104. The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is

A)  Pain

B)  Impaired gas exchange

C)  Cardiac output altered: decreased

D)  Fluid volume excess

The correct answer is C: Cardiac output altered decreased

 

 

105. The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the health care provider?

A)  Lifts head from the prone position

B)  Rolls from abdomen to back

C)  Responds to parents' voices

D)  Falls forward when sitting

The correct answer is D: Falls forward when sitting. Sitting without support is expected at this age.

 

106. A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement?

A)  Have respiratory support equipment available

B)  Immediately place her in the seclusion room

C)  Assess the client for anxiety and agitation

D)  Administer PRN dose of IM antipsychotic medication

The correct answer is A: Have respiratory support equipment available

 

 

107. The nurse walks into a client’s room and finds the client lying still and silent on the floor. The nurse should first A) Assess the client’s airway

B)  Call for help

C)  Establish that the client is unresponsive D) See if anyone saw the client fall

The correct answer is C: Establish that the client is unresponsive

 

108. The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water

seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to

A)  Check for subcutaneous emphysema in the upper torso

B)  Reposition the client to a position of comfort

C)  Call the health care provider as soon as possible

D)  Check for any increase in the amount of thoracic drainage

The correct answer is A: Check for subcutaneous emphysema in the upper torso

 

109. The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these demonstrates the normal pathway?

A) AV node, SA node, Bundle of His, Purkinje fibers

B)  Purkinje fibers, SA node, AV node, Bundle of His C) Bundle of His, Purkinje fibers, SA node , AV node

D) SA node, AV node, Bundle of His, Purkinje fibers

The correct answer is D: SA node, AV node,

Bundle of His, Purkinje fibers

 

 

110. When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?

A)  Try to vigorously stimulate normal breathing

B)  Ask the RN to assess the vital signs

C)  Measure the pulse oximetry

D)  Continue to monitor respirations

The correct answer is D: 4. Continue to monitor respirations

 

 

111. A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: “The manager makes all decisions and

rarely asks for our input.” The best description of the nurse manager’s management style is

A)  Participative or democratic

B)  Ultraliberal or communicative

C)  Autocratic or authoritarian

D)  Laissez faire or permissive

The correct answer is C: Autocratic or authoritarian

 

 

112. A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse “I’ve made some decisions about my life.” What should be the nurse’s initial response? A) “You’ve made some decisions.”

B)  “Are you thinking about killing yourself?”

C)  “I’m so glad to hear that you’ve made some decisions.”

D)  “You need to discuss your decisions with your therapist.”

The correct answer is B: “Are you thinking about killing yourself?”

 

 

113. The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, what must the nurse understand about adolescents with hemophilia? A) Must have structured activities

B)  Often take part in active sports

C)  Explain limitations to peer groups

D) Avoid risks after bleeding episodes

The correct answer is B: Often take part in active sports

 

114. When an autistic client begins to eat with her hands, the nurse can best handle the problem by

A)  Placing the spoon in the client’s hand and stating, “Use the spoon to eat your food.”

B)  Commenting “I believe you know better than to eat with your hand.”

C)  Jokingly stating, “Well I guess fingers sometimes work better than spoons.” D) Removing the food and stating “You can’t have anymore food until you use the spoon.”

The correct answer is A: Placing the spoon in the client’s hand and stating “Use the spoon to eat your food.”

 

 

115. In assessing the healing of a client’s wound during a home visit, which of the following is the best indicator of good healing?

A)  White patches

B)  Green drainage

C)  Reddened tissue

D)  Eschar development

The correct answer is C: Reddened tissue

 

 

116. Which therapeutic communication skill is most likely to encourage a depressed client to vent feelings?

A)  Direct confrontation

B)  Reality orientation

C)  Projective identification

D)  Active listening

The correct answer is D: Active listening

 

117. In order to enhance a client’s response to medication for chest pain from acute angina, the nurse should emphasize

A)  Learning relaxation techniques

B)  Limiting alcohol use

C)  Eating smaller meals

D)  Avoiding passive smoke

The correct answer is A: Learning relaxation techniques

 

 

118. The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?

A)  Arterial septal defect

B)  Patent ductus arteriosus

C)  Aortic stenosis

D)  Ventricular septal defect

The correct answer is D: Ventricular septal defect

 

 

119. Clients with mitral stenosis would likely manifest findings associated with congestion in the

A)  Pulmonary circulation

B)  Descending aorta

C)  Superior vena cava

D)  Bundle of His

The correct answer is A: Pulmonary circulation

 

 

120. The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women? A) Low tar cigarettes are less harmful during pregnancy

B)  There is a relationship between smoking and low birth weight

C)  The placenta serves as a barrier to nicotine

D)  Moderate smoking is effective in weight control

The correct answer is B: There is a relationship between smoking and low birth weight 121. What is the best way for the nurse to accomplish a health history on a 14 year-old client?

A)  Have the mother present to verify information

B)  Allow an opportunity for the teen to express feelings C) Use the same type of language as the adolescent

D) Focus the discussion of risk factors in the peer group

The correct answer is B: Allow an opportunity for the teen to express feelings

 

 

122. What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?

A) The disease will incubate longer and progress more slowly in this infant B) The infant is very susceptible to infections

C) Growth and development patterns will proceed at a normal rate D) Careful monitoring of renal function is indicated

The correct answer is B: The infant is very susceptible to infections

 

 

123. While planning care for a preschool aged child, the nurse understands developmental needs. Which of the following would be of the most concern to the nurse? A) Playing imaginatively

B)  Expressing shame

C)  Identifying with family

D)  Exploring the playroom

The correct answer is B: Expressing shame

 

 

124. A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important to emphasize to the client? A) Maintain a low sodium diet

B)  Take a diuretic with lithium

C)  Come in for evaluation of serum lithium levels every 1-3 months

D)  Have blood lithium levels drawn during the summer months

The correct answer is D: Have blood lithium levels drawn during the summer months

 

 

125. While teaching a client about their medications, the client asks how long it will take before the effects of lithium take place. What is the best response of the nurse?

A)  Immediately

B)  Several days

C)  2 weeks

D)  1 month

The correct answer is C: 2 weeks

 

 

126. The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include

A)  Pointing out inconsistencies in speech patterns to correct thought disorders

B)  Accepting client and the client’s behavior unconditionally

C)  Encouraging dependency in order to develop ego controls D) Consistent limit-setting enforced 24 hours per day

Review Information: The correct answer is D: Consistent limit-setting enforced 24 hours per day

 

 

127. Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called

A)  Craving

B)  Crashing

C)  Outward bound

D)  Nodding out

The correct answer is B: Crashing

 

 

128. The nurse asks a client with a history of alcoholism about the client’s drinking behavior. The client states “I didn’t hurt anyone. I just like to have a good time, and drinking helps me to relax.” The client is using which defense mechanism? A) Denial

B)  Projection

C)  Intellectualization

D)  Rationalization

The correct answer is D: Rationalization

 

 

129. One reason that domestic violence remains extensively undetected is A) Few battered victims seek medical care

B)  There is typically a series of minor, vague complaints

C)  Expenses due to police and court costs are prohibitive

D)  Very little knowledge is currently known about batterers and battering relationships

The correct answer is B: There is typically a series of minor, vague complaints

130. A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find? A) S3 heart sound

B)  Thready pulse

C)  Flattened neck veins

D)  Hypoventilation

The correct answer is A: Auscultation of an

 

 

131. The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?

A)  Observe for edema proximal to the site

B)  Irrigate with 5 mls of 0.9% Normal Saline

C)  Palpate for a thrill over the fistula

D)  Check color and warmth in the extremity

The correct answer is C: Palpate for a thrill over the fistula

 

132. A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 20-40 mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug administration, what should the nurse do next? A) Give the medication as ordered

B)  Call the health care provider to clarify the dose

C)  Recognize that antibiotics are over-prescribed

D)  Hold the medication as the dosage is too low

The correct answer is A: Give the medication as ordered

 

 

133. The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when

A) An individual displays restlessness

B)  There are obvious signs of depression

C)  Conducting any health assessment D) The resident reports memory lapses

The correct answer is C: Conducting any health assessment

 

 

134. The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization?

A)  Younger siblings adapt very well

B)  Visitation is helpful for both C) The siblings may enjoy privacy

D) Those cared for at home cope better

The correct answer is B: Visitation is helpful for both

 

 

135. Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the health care provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse?

A)  Tell the parents to bring the child to the clinic for further evaluation

B)  Refer the school officials to printed materials about this viral illness C) Inform the teacher that the child is receiving antibiotics for the rash

D) Explain that this rash is not contagious and does not require isolation

The correct answer is D: Explain that this rash is not contagious and does not require isolation

 

 

136. When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority?

A)  Follow-up on lab values before the visit

B)  Observe client findings for the effectiveness of antibiotics

C)  Ask for a log of urinary output

D)  As for the log of the oral intake

The correct answer is C: Ask for a log of urinary output

 

 

137. The nurse is caring for a newborn who has just been diagnosed with hypospadias. After discussing the defect with the parents, the nurse should expect that

A)  Circumcision can be performed at any time

B)  Initial repair is delayed until ages 6-8

C)  Post-operative appearance will be normal

D)  Surgery will be performed in stages

The correct answer is D: Surgery will be performed in stages

 

 

138. The nurse is assessing a client on admission to a community mental health center. The client discloses that she has been thinking about ending her life. The nurse’s best response would be

A) “Do you want to discuss this with your pastor?” B) “We will help you deal with those thoughts.”

C) “Is your life so terrible that you want to end it?” D) “Have you thought about how you would do it?”

The correct answer is D: “Have you thought about how you would do it?”

 

  

139. The nursing care plan for a client with decreased adrenal function should include

A)  Encouraging activity

B)  Placing client in reverse isolation

C)  Limiting visitors

D)  Measures to prevent constipation

The correct answer is C: Limiting visitors

 

 

140. The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?

A)  Cough and deep breathe every 2 hours

B)  Place the client in contact isolation C) Provide a diet high in protein D) Institute seizure precautions

The correct answer is A: Cough and deep breathe every 2 hours

 

 

141. Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)? A) Neuromalignant syndrome

B)  Acute extrapyramidal syndrome

C)  Glaucoma, prostatic hypertrophy

D)  Parkinson’s disease, atypical tremors

The correct answer is C: Glaucoma, prostatic hypertrophy

 

 

142. The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?

A)  Perform defibrillation

B)  Administer epinephrine as ordered

C)  Assess for presence of pulse

D)  Institute CPR

The correct answer is C: Assess for presence of pulse

 

 

143. During the use of an interpreter to teach a client about a procedure to do in the home the nurse should take which approach?

A) Speak directly to the interpreter while presenting information and use pauses for questions

B)  Talk to the interpreter in advance and leave the client and interpreter alone

C)  Include a family member and direct communications to that person

D) Face the client while presenting the information as the interpreter talks in the native language

The correct answer is D: Face the client while presenting the information as the interpreter talks in the native language .

 

144. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby’s father. Which of the following nursing interventions is a priority?

A)  Counsel the woman to consent to HIV screening

B)  Perform tests for sexually transmitted diseases

C)  Discuss her high risk for cervical cancer

D)  Refer the client to a family planning clinic

The correct answer is A: Counsel the woman to consent to HIV screening

 

 

145. A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?

A)  High Fowler’s

B)  Supine

C)  Left lateral

D)  Low Fowler’s

The correct answer is A: High Fowler'’s

 

 

146. A nurse who is evaluating a mentally retarded 2 year-old in a clinic should stress which goal when talking to the child’s mother?

A)  Teaching the child self care skills

B)  Preparing for independent toielting

C)  Promoting the child’s optimal development

D)  Helping the family decide on long term care

The correct answer is C: Promoting the child'’s optimal development

 

 

147. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist the client with nutrition needs, the nurse should A) Offer small meals of high calorie soft food

B)  Assist the client to sit in a chair for meals

C)  Provide additional servings of fruits and raw vegetables

D)  Encourage the client to eat fish, liver and chicken

The correct answer is A: Offer small meals of high calorie soft food

 

  

148. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis? A) Several otitis media episodes in the last year

B)  Weight and height in 10th percentile since birth

C)  Takes frequent rest periods while playing D) Changing food preferences and dislikes

The correct answer is C: Takes frequent rest periods while playing

 

 

149. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment

parameter that will indicate that the child has adequate fluid replacement is

A)  Urinary output of 30 ml per hour

B)  No complaints of thirst

C)  Increased hematocrit

D)  Good skin turgor around burn

The correct answer is A: Urinary output of 30 ml per hour

 

150. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most

likely explain these findings?

A) Ingestion of tetracycline B) Excessive fluoride intake

C)  Oral iron therapy

D)  Poor dental hygiene

The correct answer is B: Excessive fluoride intake

 

 

151. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice?

A) An 18 month-old who ate an undetermined amount of crystal drain cleaner

B)  A 14 month-old who chewed 2 leaves of a philodendron plant

C)  A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium)

D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid

The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain cleaner

152. Which of these is an example of a variation in the newborn resulting from the presence of maternal hormones? A) Engorgement of the breasts

B)  Mongolian spots

C)  Edema of the scrotum

D)  Lanugo

The correct answer is A: Engorgement of the breasts

 

 

153. A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?

A)  Elbow

B)  Mummy

C)  Jacket

D)  Clove hitch

The correct answer is A: Elbow

 

 

154. A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to

A)  Notify the health care provider immediately

B)  Suggest in-patient psychiatric care

C)  Respect the client’s confidential disclosure

D)  Phone the family to warn them of the risk

The correct answer is A: Notify the health care provider immediately

 

 

155. A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?

A)  Altered nutrition: less than body requirements

B)  Potential complication hemorrhage

C)  Ineffective individual coping

D)  Fluid volume excess

The correct answer is B: Potential complication hemorrhage

 

 

156. While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?

A)  Strange bed and surroundings

B)  Separation from parents C) Presence of other toddlers

 

D) Unfamiliar toys and games

The correct answer is B: Separation from parents

 

 

157. Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)?

A)  Direct sunlight

B)  Foods containing tyramine

C)  Foods fermented with yeast

D)  Canned citrus fruit drinks

The correct answer is A: Avoid direct sunlight

 

158. The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is

A) “You think that someone wants to poison you?” B) “Why do you think the food is poisoned?”

C)  “These feelings are a symptom of your illness.”

D)  “You’re safe here. I won’t let anyone poison you.”

The correct answer is A: “You think that someone wants to poison you?”

 

 

159. The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that A) The client should remain on bed rest in a semi-Fowler’s position

B)  The client should alternate ambulation with bed rest with legs elevated

C)  The client may ambulate and sit in chair as tolerated

D) The client may ambulate as tolerated and remain in semi-Fowler position in bed The correct answer is B: The client should alternate ambulation with bed rest with legs elevated

 

 

160. The nurse is performing physical assessments on adolescents. When would the nurse anticipate that females experience growth spurts? A) About 2 years earlier than males

B)  About the same time as males

C)  Just prior to the onset of puberty

D)  That increase height by 4 inches each year

The correct answer is A: About 2 years earlier than males

  

2018 HESI EXIT V5

 

1. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

A) Nutrition B) Elimination

C) Activity D) Safety

The correct answer is D: Safety

 

 

2. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?

A)  They are able to make simple association of ideas

B)  They are able to think logically in organizing facts

C)  Interpretation of events originate from their own perspective

D)  Conclusions are based on previous experiences

The correct answer is B: Think logically in organizing facts

 

3. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first?

A)  Clear the area of any hazards

B)  Place the child on the side

C)  Restrain the child

D)  Give the prescribed anticonvulsant

The correct answer is B: Place the child on the side

 

 

4. The nurse is reviewing a depressed client’s history from an earlier admission.

Documentation of anhedonia is noted. The nurse understands that this finding refers to

A)  Reports of difficulty falling and staying asleep

B)  Expression of persistent suicidal thoughts

C)  Lack of enjoyment in usual pleasures D) Reduced senses of taste and smell

The correct answer is C: Lack of enjoyment in usual pleasures

 

 

5. A client has just returned to the medical-surgical unit following a segmental lung

resection. After assessing the client, the first nursing action would be to

A)  Administer pain medication

B)  Suction excessive tracheobronchial secretions

C)  Assist client to turn, deep breathe and cough

D)  Monitor oxygen saturation

The correct answer is B: Suction excessive tracheobronchial secretions

 

6. While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?

A)  Compulsive behavior

B)  Sense of impending doom

C)  Fear of flying

D)  Predictable episodes

The correct answer is B: Sense of impending doom

 

 

7. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?

A)  Arrange to change client care assignments

B)  Explain that this behavior is expected

C)  Discuss the appropriate use of “time-out”

D)  Explain that the child needs extra attention

The correct answer is B: Explain that this behavior is expected

 

 

8. A 15 year-old client with a lengthy confining illness is at risk for altered growth and development of which task?

A)  Loss of control

B)  Insecurity

C)  Dependence

D)  Lack of trust

The correct answer is C: Dependence

 

 

9. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children? A) Sports and games with rules

B)  Finger paints and water play

C)  “Dress-up” clothes and props

D)  Chess and television programs

The correct answer is A: Sports and games with rules

 

 

10. The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is

A)  “Eat a balanced diet for your age.”

B)  “Increase your intake of protein and Vitamin A.”

C)  “Decrease fatty foods from your diet.”

D)  “Do not use caffeine in any form, including chocolate.”

The correct answer is A: “Eat a balanced diet for your age.”

 

 

11. The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds

A)  “The complaints of at least 3 common findings.”

B)  “The absence of any opportunistic infection.”

C)  “CD4 lymphocyte count is less than 200.” D) “Developmental delays in children.”

The correct answer is C: “CD4 lymphocyte count is less than 200.”

 

12. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate? A) Offer ice cream every 2 hours

B)  Place the child in a supine position

C)  Allow the child to drink through a straw

D)  Observe swallowing patterns

The correct answer is D: Observe swallowing patterns

 

 

13. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? A) Acceptance of the pregnancy

B)  Focus on fetal development

C)  Anticipation of the birth

D) Ambivalence about pregnancy

The correct answer is C: Anticipation of the birth

 

 

14. The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions? A) Administration of cough suppressants

B)  Increasing oral fluid intake to 3000 cc per day

C)  Maintaining bed rest with bathroom privileges

D)  Performing chest physiotherapy twice a day

The correct answer is B: Increasing oral fluid intake to 3000 cc per day

 

 

15. The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?

A) A 13 month-old unable to walk

B)  A 20 month-old only using 2 and 3 word sentences

C)  A 24 month-old who cries during examination

D) A 30 month-old only drinking from a sip cup

The correct answer is D: A 30 month-old only drinking from a sip cup

 

16. Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes? A) Give written pre and post tests

B)  Ask questions during practice

C)  Allow another diabetic to assist

D)  Observe a return demonstration

The correct answer is D: Observe a return demonstration

 

 

17. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

A)  Elevate leg on 2 pillows

B)  Apply support stockings

C)  Apply warm compresses

D)  Maintain complete bed rest

The correct answer is A: Elevate leg on 2 pillows

 

 

18. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to

this nurse is which child?

A)  Congenital cardiac defects

B)  An acute febrile illness

C)  Prolonged hypoxemia

D)  Severe multiple trauma

The correct answer is C: Prolonged hypoxemia

 

 

19. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to

A) A social worker from the local hospital

B)  An occupational therapist from the community center

C)  A physical therapist from the rehabilitation agency

D) Another client with diabetes mellitus and takes insulin

The correct answer is B: An occupational therapist from the community center

 

 

20. A priority goal of involuntary hospitalization of the severely mentally ill client is A) Re-orientation to reality

B)  Elimination of symptoms

C)  Protection from harm to self or others

The correct answer is C: Protection from self harm and harm to others

 

 

21. The nurse is caring for a client with a long leg cast. During discharge teaching about

appropriate exercises for the affected extremity, the nurse should recommend

A)  Isometric

B)  Range of motion

C)  Aerobic

D)  Isotonic

The correct answer is A: Isometric

 

 

22. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report A) Loss of consciousness

B)  Feeding problems

C)  Poor weight gain D) Fatigue with crying

The correct answer is A: Loss of consciousness

 

 

23. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would

A)  Instruct the client to maintain a regular diet the day prior to the examination

B)  Restrict the client’s fluid intake 4 hours prior to the examination C) Administer a laxative to the client the evening before the examination D) Inform the client that only 1 x-ray of his abdomen is necessary

The correct answer is C: Administer a laxative to the client the evening before the examination

 

 

24. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? A) Altered tissue perfusion

B)  Risk for fluid volume deficit

C)  High risk for hemorrhage

D)  Risk for infection

The correct answer is D: Risk for infection

 

25. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that

A) Circumcision is delayed so the foreskin can be used for the surgical repair B) This procedure is contraindicated because of the permanent defect

C)  There is no medical indication for performing a circumcision on any child

D)  The procedure should be performed as soon as the infant is stable

The correct answer is A: Circumcision is delayed so the foreskin can be used for the surgical repair

 

 

26. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?

A)  Confusion

B)  Loss of half of visual field

C)  Shallow respirations

D)  Tonic-clonic seizures

The correct answer is C: Shallow respirations

 

 

27. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings?

A)  These side effects are common and should subside in a few days

B)  The client is probably having an allergic reaction and should discontinue the drug

C)  Taking the lithium on an empty stomach should decrease these symptoms

D)  Decreasing dietary intake of sodium and fluids should minimize the side effects The correct answer is A: These side effects are common and should subside in a few days

 

 

28. A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?

A)  Ask the client if he has noticed any bleeding or dark stools

B)  Tell the client to call 911 and go to the emergency department immediately

C)  Schedule a repeat Hemoglobin and Hematocrit in 1 month

D)  Tell the client to schedule an appointment with a hematologist

The correct answer is A: Ask the client if he has noticed any bleeding or dark stools

 

 

29. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the

A)  Surgical repair of a diseased coronary artery

B)  Placement of an automatic internal cardiac defibrillator C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow

D) Non-invasive radiographic examination of the heart

The correct answer is C: Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow

 

 

30. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? A) Institute seizure precautions

B)  Weigh the child twice per shift

C)  Encourage the child to eat protein-rich foods D) Relieve boredom through physical activity

The correct answer is A: Institute seizure precautions

 

 

31. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of

D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute?

A)  60 microdrops/minute

B)  20 microdrops/minute

C)  30 microdrops/minute

D)  40 microdrops/minute

The correct answer is A: 60 microdrops/minute

2 gm=2000 mgm

2000 mgm/500 cc = 4 mgm/x cc 2000x

= 2000

x= 2000/2000 = 1 cc of IV solution/minute CC x 60 microdrops = 60 microdrops/minute

 

32. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?

A)  Review the client’s weight pattern over the year

B)  Ask the mother to record her diet for the last 24 hours C) Encourage her to talk about her view of herself

D) Give her several pamphlets on postpartum nutrition

The correct answer is C: Encourage her to talk about her view of herself

 

 

33. To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would

A) Assist the client to use the bedside commode

B)  Administer stool softeners every day as ordered C) Administer anti dysrhythmics prn as ordered

D) Maintain the client on strict bed rest

The correct answer is B: Administer stool softeners every day as ordered

 

 

34. A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should

A) Expose the cast to air and turn the child frequently B) Use a heat lamp to reduce the drying time

C)  Handle the cast with the abductor bar

D)  Turn the child as little as possible

The correct answer is A: Expose the cast to air and turn the child frequently

 

 

35. The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate postoperative period? A) Raise the head of the bed at least 30 degrees

B)  Encourage ambulation within 24 hours

C)  Maintain in a flat position, logrolling as needed

D)  Encourage leg contraction and relaxation after 48 hours

The correct answer is C: Maintain in a flat position, logrolling as needed

 

 

36. A client was admitted to the psychiatric unit after complaining to her friends and

family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to

A)  Convince the client that the hospital staff is trying to help

B)  Help the client to enter into group recreational activities C) Provide interactions to help the client learn to trust staff

D) Arrange the environment to limit the client’s contact with other clients The correct answer is C: Provide interactions to help the client learn to trust staff

 

 

37. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate? A) Unequal leg length

B)  Limited adduction

C)  Diminished femoral pulses

D)  Symmetrical gluteal folds

The correct answer is A: Unequal leg length

 

38. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to A) A cerebral vascular accident

B)  Postoperative meningitis

C)  Medication reaction

D)  Metabolic alkalosis

The correct answer is A: A cerebral vascular accident

 

 

39. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that

A) AGN is a streptococcal infection that involves the kidney tubules B) The disease is easily transmissible in schools and camps

C)   The illness is usually associated with chronic respiratory infections

D)   It is not “caught” but is a response to a previous B-hemolytic strep infection The correct answer is D: It is not “caught” but is a response to a previous B-hemolytic strep infection

 

40. A couple asks the nurse about risks of several birth control methods. What is he most appropriate response by the nurse?

A)  Norplant is safe and may be removed easily

B)  Oral contraceptives should not be used by smokers

C)  Depo-Provera is convenient with few side effects

D)  The IUD gives protection from pregnancy and infection

The correct answer is B: Oral contraceptives should not be used by smokers

 

 

41. A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale? A) “Nursing will help contract the uterus and reduce your risk of bleeding.”

B)  “Breastfeeding twins will take too much energy after the hemorrhage.”

C)  “The blood transfusion may increase the risks to you and the babies.” D) “Lactation should be delayed until the “real milk” is secreted.”

The correct answer is A: “Nursing will help contract the uterus and reduce your risk of bleeding.”

 

 

42. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure? A) Place pillows under the knees

B)  Use elastic stockings continuously

C)  Encourage range of motion and ambulation

D)  Massage the legs twice daily

The correct answer is C: Encourage range of motion and ambulation

 

43. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33%

normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately? A) 3 episodes of vomiting in 1 hour

B)  Periodic crying and irritability

C)  Vigorous sucking on a pacifier

D)  No measurable voiding in 4 hours

The correct answer is D: No measurable voiding in 4 hours

 

44. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?

A)    “Addiction usually causes people to feel guilty. Don’t worry, it is a typical response due to your drinking behavior.”

B)     “What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?”

C)     “Don’t focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs.”

D)    “You’ve caused a great deal of pain to your family and close friends, so it will take time to undo all the things you’ve done.”

The correct answer is B: “What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?”

 

45. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when “his eyes rolled upward.” The nurse recognizes this as what type of side effect?

A)  Oculogyric crisis

B)  Tardive dyskinesia

C)  Nystagmus

D)  Dysphagia

The correct answer is A: Oculogyric crisis

 

 

46. Which of the following measures would be appropriate for the nurse to teach the parent of a nine month-old infant about diaper dermatitis? A) Use only cloth diapers that are rinsed in bleach

B)  Do not use occlusive ointments on the rash

C)  Use commercial baby wipes with each diaper change

D)  Discontinue a new food that was added to the infant’s diet just prior to the rash The correct answer is D: Discontinue a new food that was added to the infant'’s diet just prior to the rash

 

 

47. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child’s constantly saying “no” and his refusal to follow her directions. The nurse explains this is

normal for his age, as negativism is attempting to meet which developmental need? A) Trust

B)  Initiative

C)  Independence

D)  Self-esteem

The correct answer is C: Independence

 

 

48. Which behavioral characteristic describes the domestic abuser?

A)  Alcoholic

B)  Over confident

C)  High tolerance for frustrations

D)  Low self-esteem

The correct answer is D: Low self-esteem

 

 

49. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing

A) “This action of my lips helps to keep my airway open.” B) “I can expel more when I pucker up my lips to breathe out.”

C)  “My mouth doesn’t get as dry when I breathe with pursed lips.”

D) “By prolonging breathing out with pursed lips the little areas in my lungs don’t collapse.”

The correct answer is D: “By prolonging breathing out with pursed lips my little areas in my lungs don'’t collapse.”

 

 

50. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?

A)  “I have constant blurred vision.”

B)  “I can’t see on my left side.”

C)  “I have to turn my head to see my room.” D) “I have specks floating in my eyes.”

The correct answer is C: “I have to turn my head to see my room.”

 

 

51. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression”?

A)  “I don’t remember anything about what happened to me.”

B)  “I’d rather not talk about it right now.”

C)  “It’s all the other guy’s fault! He was going too fast.”

D)  “My mother is heartbroken about this.”

The correct answer is A: “I don'’t remember anything about what happened to me.”

 

 

52. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action?

A)  Check vital signs

B)  Massage the fundus

C)  Offer a bedpan

D)  Check for perineal lacerations

The correct answer is B: Massage the fundus

 

 

53. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age? A) Double the birth weight

B)  Triple the birth weight

C)  Gain 6 ounces each week

D) Add 2 pounds each month

The correct answer is A: Double the birth weight

 

 

54. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to

A) Give the client orientation materials and review the unit rules and regulations B) Introduce him/herself and accompany the client to the client’s room

C)  Take the client to the day room and introduce her to the other clients

D) Ask the nursing assistant to get the client’s vital signs and complete the admission search

The correct answer is B: Introduce him/herself and accompany the client to the client’s room

 

 

 

55. A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client

A)  Has increased airway obstruction

B)  Has improved airway obstruction

C)  Needs to be suctioned

D)  Exhibits hyperventilation

The correct answer is A: Has increased airway obstruction

 

 

56. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse? A) “Focus on your sons' needs during the first days at home.”

B)  “Tell each child what he can do to help with the baby.”

C)  “Suggest that your husband spend more time with the boys.”

D)  “Ask the children what they would like to do for the newborn.”

The correct answer is A: “Focus on your sons'' needs during the first days at home.”

 

 

57. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is A) Progressive failure to adapt

B)  Feelings of anger or hostility

C)  Reunion wish or fantasy

D)  Feelings of alienation or isolation

The correct answer is D: Feelings of alienation or isolation

 

 

58. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize

A)  They can expect the child will be mentally retarded

B)  Administration of thyroid hormone will prevent problems

C)  This rare problem is always hereditary

D)  Physical growth/development will be delayed

The correct answer is B: Administration of thyroid hormone will prevent problems

 

 

59. A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?

A)  Holistic healing

B)  Spiritual advising C) Herbal preparations

D) Witchcraft potions

The correct answer is A: Holistic healing

 

 

60. In addition to disturbances in mental awareness and orientation, a client with

cognitive impairment is also likely to show loss of ability in

A)  Hearing, speech, and sight

B)  Endurance, strength, and mobility C) Learning, creativity, and judgment

D) Balance, flexibility, and coordination

The correct answer is C: Learning, creativity and judgment