HESI EXIT EXAM 2022 Version 1

PN HESI EXIT EXAM 2019 PN HESI EXIT EXAM 2020 PN HESI EXIT EXAM 2021 PN HESI EXIT EXAM 2022 PN 2019-2022 HESI EXIT V1 Check Financial institution 1. Which data is a precedence for the RN to strengthen to an older shopper after intravenous pylegraphy? A) Eat a lightweight food plan for the remainder of the day B) Relaxation for the subsequent 24 hours because the preparation and the take a look at is tiring. C) Throughout waking hours drink at the very least 1 8-ounce glass of fluid each hour for the subsequent 2 days D) Measure the urine output for the subsequent day and instantly notify the well being care supplier if it ought to lower. Measure the urine output for the subsequent day and instantly notify the well being care supplier if it ought to lower. 2. A shopper has altered renal perform and is being handled at house. The nurse acknowledges that probably the most correct indicator of fluid stability in the course of the weekly visits is A) distinction within the consumption and output B) modifications within the mucous membranes C) pores and skin turgor D) weekly weight weekly weight 3. A shopper has been identified with Zollinger-Ellison syndrome.Which data is most vital for the nurse to strengthen with the shopper? A) It’s a situation during which a number of tumors known as gastrinomas kind within the pancreas or within the higher a part of the small gut (duodenum) B) It’s crucial to report promptly to your well being care supplier any findings of peptic ulcers c)Therapy consists of medicines to scale back acid and heal any peptic ulcers and, if potential, surgical procedure to take away any tumors D)With the typical age at analysis at 50 years the peptic ulcers could happen at uncommon areas of the abdomen or gut It’s crucial to report promptly to your well being care supplier any findings of peptic ulcers . 4. A primigravida within the third trimester is hospitalized for preeclampsia. The nurse determines that the shopper’s blood stress is rising. Which motion ought to the nurse take first? A) Test the protein degree in urine B) Have the shopper flip to the left facet C) Take the temperature D) Monitor the urine output Have the shopper flip to the left facet 5. The nurse is caring for a shopper in atrial fibrillation. The atrial coronary heart charge is 250 and the ventricular charge is managed at 75. Which of the next findings is trigger for probably the most concern? A) Diminished bowel sounds B) Lack of urge for food C) A chilly, pale decrease leg D) Tachypnea A chilly, pale decrease leg 6. The shopper with infective endocarditis should be assessed continuously by the house well being nurse. Which discovering means that antibiotic remedy isn’t efficient, and should be reported by the nurse instantly to the healthcare supplier? A) Nausea and vomiting B) Fever of 103 levels Fahrenheit (39.5 levels Celsius) C) Diffuse macular rash D) Muscle tenderness Fever of 103 levels F (39.5 levels C) 7. A shopper who had a vasectomy is within the put up restoration unit at an outpatient clinic. Which of those factors is most vital to be strengthened by the nurse? A) Till the well being care supplier has decided that your ejaculate would not include sperm, proceed to make use of one other type of contraception. B) This process would not impede the manufacturing of male hormones or the manufacturing of sperm within the testicles. The sperm can not enter your semen and no sperm are in your ejaculate. C) After your vasectomy, strenuous exercise must be averted for at the very least 48 hours. In case your work would not contain exhausting bodily labor, you’ll be able to return to your job as quickly as you are feeling as much as it. The stitches usually dissolve in seven to 10 days. D) The well being care supplier at this clinic recommends relaxation, ice, an athletic supporter or over-the-counter ache medicine to alleviate any discomfort. Till the well being care supplier has decided that your ejaculate would not include sperm, proceed to make use of one other type of contraception. 8. A shopper who’s to have antineoplastic chemotherapy tells the nurses of a concern of being sick on a regular basis and needs to attempt acupuncture. Which of those beliefs said by the shopper can be incorrect about acupuncture? A) Some needles go as deep as 3 inches, relying on the place they’re positioned within the physique and what the therapy is for. The needles normally are left in for 15 to half-hour. B) In conventional Chinese language medication, imbalances within the primary energetic stream of life — referred to as qi or chi — are thought to trigger sickness. * C) The stream of life is believed to stream via main pathways or nerve clusters in your physique. D) By inserting extraordinarily high quality needles into a number of the over 400 acupuncture factors in numerous mixtures it’s believed that vitality stream will rebalance to permit the physique’s pure therapeutic mechanisms to take over. The stream of life is believed to stream via main pathways or nerve clusters in your physique. 9. The nurse is discussing with a bunch of scholars the illness Kawasaki. What assertion made by a scholar about Kawasaki illness is inaccurate? A)It additionally known as mucocutaneous lymph node syndrome as a result of it impacts the mucous membranes (contained in the mouth, throat and nostril), pores and skin and lymph nodes. B)Within the second section of the illness, findings embody peeling of the pores and skin on the palms and ft with joint and stomach ache C) Kawasaki illness happens most frequently in boys, youngsters youthful than age 5 and kids of Hispanic descent D) Initially findings are a sudden excessive fever, normally above 104 levels Fahrenheit, which lasts 1 to2 weeks Kawasaki illness happens most frequently in boys, youngsters youthful than age 5 and kids of Hispanic descent 10. A shopper has viral pneumonia affecting 2/3 of the correct lung. What can be the most effective place to show the shopper to lie in each different hour throughout first 12 hours after admission? A) Facet-lying on the left with the pinnacle elevated 10 levels B) Facet-lying on the left with the pinnacle elevated 35 levels C) Facet-lying on the correct wil the pinnacle elevated 10 levels D) Facet-lying on the correct with the pinnacle elevated 35 levels Facet-lying on the left with the pinnacle elevated 10 levels 11. A shopper has an indwelling catheter with steady bladder irrigation after present process a transurethral resection of the prostate (TURP) 12 hours in the past. Which discovering at the moment must be reported to the well being care supplier? A) Mild, pink urine B) occasional suprapubic cramping C) minimal drainage into the urinary assortment bag D) complaints of the sensation of pulling on the urinary catheter minimal drainage into the urinary assortment bag 12. A nurse is performing CPR on an grownup who went into cardiopulmonary arrest. One other nurse enters the room in response to the decision. After checking the shopper’s pulse and respirations, what must be the perform of the second nurse? A) Relieve the nurse performing CPR B) Go get the code cart C) Take part with the compressions or respiratory D) Validate the shopper’s superior directive Take part with the compressions or respiratory 13. The nurse assesses a 72 year-old shopper who was admitted for proper sided congestive coronary heart failure. Which of the next would the nurse anticipate discovering? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar crackles Jugular vein distention 14. A shopper with coronary heart failure has a prescription for digoxin. The nurse is conscious that enough potassium must be included within the food plan as a result of hypokalemia together with this medicine A) Can predispose to dysrhythmias B) Might result in oliguria C) Might trigger irritability and nervousness D) Typically alters consciousness Can predispose to dysrhythmias 15. A nurse assesses a younger grownup within the emergency room following a motorized vehicle accident. Which of the next neurological indicators is of most concern? A) Flaccid paralysis B) Pupils mounted and dilated C) Diminished spinal reflexes D) Diminished sensory responses Pupils mounted and dilated 16. A 14 year-old with a historical past of sickle cell illness is admitted to the hospital with a analysis of vaso-occlusive disaster. Which statements by the shopper can be most indicative of the etiology of this disaster? A) ”I knew this may occur. I have been consuming an excessive amount of purple meat currently.” B) ”I actually loved my fishing journey yesterday. I caught 2 fish.” C) ”I’ve actually been working exhausting practising with the controversy crew in school.” D) ”I went to the well being care supplier final week for a chilly and I’ve gotten worse.” “I went to the physician final week for a chilly and I’ve gotten worse.” 17. Which these findings would the nurse extra intently affiliate with anemia in a ten month-old toddler? A) Hemoglobin degree of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A coronary heart charge between 140 to 160 Pale mucosa of the eyelids and lips 18. The nurse is caring for a shopper in hypertensive disaster in an intensive care unit. The precedence evaluation within the first hour of care is A) Coronary heart charge B) Pedal pulses C) Lung sounds D) Pupil responses Pupil responses 19. Which of those shoppers who’re all within the terminal stage of most cancers is least applicable to recommend using affected person managed analgesia (PCA) with a pump? A) A younger grownup with a historical past of Down’s syndrome B) An adolescent who reads at a 4th grade degree C) An aged shopper with quite a few arthritic nodules on the palms D) A preschooler with intermittent episodes of alertness A preschooler with intermittent episodes of alertness 20. The nurse is about to evaluate a 6 month-old youngster with nonorganic failure-to thrive (NOFTT). Upon coming into the room, the nurse would count on the newborn to be A) Irritable and “colicky” with no makes an attempt to drag to standing B) Alert, laughing and taking part in with a rattle, sitting with assist C) Pores and skin coloration dusky with poor pores and skin turgor over stomach D) Pale, skinny legs and arms, tired of environment Pale, skinny legs and arms, tired of environment 21. Because the nurse is talking with a bunch of teenagers which of those unintended effects of chemotherapy for most cancers would the nurse count on this group to be extra keen on in the course of the dialogue? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss Hair loss 22. Whereas caring for a shopper who was admitted with myocardial infarction (MI) 2 days in the past, the nurse notes in the present day’s temperature is 101.1 levels Fahrenheit (38.5 levels Celsius). The suitable nursing intervention is to A) Name the well being care supplier instantly B) Administer acetaminophen as ordered as that is regular at the moment C) Ship blood, urine and sputum for tradition D) Enhance the shopper’s fluid consumption Administer acetaminophen as ordered as that is regular at the moment 23. A shopper is admitted for first and second diploma burns on the face, neck, anterior chest and palms. The nurse’s precedence must be A) Cowl the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Provoke intravenous remedy D) Administer ache medicine Assess for dyspnea or stridor 24. Which of those shoppers who name the neighborhood well being clinic would the nurse ask to come back in that day to be seen by the well being care supplier? A) I began my interval and now my urine has turned vibrant purple. B) I’m an diabetic and in the present day I’ve been going to the lavatory each hour. C) I used to be began on medication yesterday for a urine an infection. Now my decrease stomach hurts once I go to the lavatory. D) I went to the lavatory and my urine appeared very purple and it didn’t harm once I went. I went to the lavatory and my urine appeared very purple and it didn’t harm once I went. 25. A center aged girl talks to the nurse within the well being care supplier’s workplace about uterine fibroids additionally known as leiomyomas or myomas. What assertion by the lady signifies extra training is required? A) I’m one out of each 4 girls that get fibroids, and of ladies my age – between the 30s or 40s, fibroids happens extra continuously. B) My fibroids are noncancerous tumors that develop slowly. C) My related issues I’ve had are pelvic stress and ache, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that trigger no issues nonetheless should be taken out. Fibroids that trigger no issues nonetheless should be taken out. 26. An aged shopper admitted after a fall begins to grab and loses consciousness. What motion by the nurse is suitable to do subsequent? A) Stick with shopper and observe for airway obstruction B) Gather pillows and pad the facet rails of the mattress C) Place an oral airway within the mouth and suction D) Announce a cardiac arrest, and help with intubation Stick with shopper and observe for airway obstruction 27. A nurse is offering care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours in the past. Labor is to be induced. On the time of the ROM the important indicators have been T-99.8 levels F, P-84, R-20, BP-130/78, and fetal coronary heart tones (FHT) 148 beats/min. Which evaluation findings taken now could also be an early indication that the shopper is creating a complication of labor? A) FHT 168 beats/min B) Temperature 100 levels Fahrenheit. C) Cervical dilation of 4 D) BP 138/88 FHT 168 beats/min 28. A shopper with pneumococcal pneumonia had been began on antibiotics 16 hours in the past. Throughout the nurse’s preliminary night rounds the nurse notices a foul odor within the room. The shopper makes all of those statements throughout their dialog. Which assertion would alert the nurse to a complication? A) “I’ve a pointy ache in my chest once I take a breath.” B) “I’ve been coughing up foul-tasting, brown, thick sputum.” C) “I’ve been sweating all day.” D) “I really feel sizzling on and off.” “I’ve been coughing up foul tasting, brown, thick sputum.” 29. The nurse is performing an evaluation on a shopper in congestive coronary heart failure. Auscultation of the guts is most probably to disclose A) S3 ventricular gallop B) Apical click on C) Systolic murmur D) Cut up S2 S3 ventricular gallop 30. Which of those observations made by the nurse throughout an excretory urogram point out a complicaton? A) The shopper complains of a salty style within the mouth when the dye is injected B) The shopper’s total physique turns a vibrant purple coloration C) The shopper states “I’ve a sense of getting heat.” D) The shopper gags and complains “ I get sick.” The shopper’s total physique turns a vibrant purple coloration 31. A shopper is identified with a spontaneous pneumothorax necessitating the insertion of a chest tube. What’s the finest rationalization for the nurse to supply this shopper? A) “The tube will drain fluid out of your chest.” B) “The tube will take away extra air out of your chest.” C) “The tube controls the quantity of air that enters your chest.” D) “The tube will seal the opening in your lung.” “The tube will take away extra air out of your chest.” 32. The nurse is reviewing laboratory outcomes on a shopper with acute renal failure. Which one of many following must be reported instantly? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L Serum potassium 6 mEq/L 33. The nurse is caring for a shopper present process the position of a central venous catheter line. Which of the next would require the nurse’s speedy consideration? A) Pallor B) Elevated temperature C) Dyspnea D) Involuntary muscle spasms Dyspnea 34. The nurse is performing a bodily evaluation on a shopper who simply had an endotracheal tube inserted. Which discovering would name for speedy motion by the nurse? A) Breath sounds could be heard bilaterally B) Mist is seen within the T-Piece C) Pulse oximetry of 88 D) Consumer is unable to talk Pulse oximetry of 88 35. A nurse checks a shopper who’s on a volume-cycled ventilator. Which discovering signifies that the shopper may have suctioning? A) drowsiness B) criticism of nausea C) pulse charge of 92 D) restlessness restlessness 36. The simplest nursing intervention to forestall atelectasis from creating in a put up operative shopper is to A) Keep ample hydration B) Help shopper to show, deep breathe, and cough C) Ambulate shopper inside 12 hours D) Splint incision Help shopper to show, deep breathe, and cough 37. When caring for a shopper with a put up proper thoracotomy who has undergone an higher lobectomy, the nurse focuses on ache administration to advertise A) Leisure and sleep B) Deep respiratory and coughing C) Incisional therapeutic D) Vary of movement workout routines Deep respiratory and coughing 38. A nurse is to gather a sputum specimen for acid-fast bacillus (AFB) from a shopper. Which motion ought to the nurse take first? A) Ask shopper to cough sputum into container B) Have the shopper take a number of deep breaths C) Present a applicable specimen container D) Help with oral hygiene Help with oral hygiene 39. The nurse is caring for a kid instantly after surgical correction of a ventricular septal defect. Which of the next nursing assessments must be a precedence? A) Blanch nail beds for coloration and refill B) Assess for put up operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses Assess for put up operative arrhythmias 40. A shopper has a historical past of power obstructive pulmonary illness (COPD). Because the nurse enters the shopper’s room, his oxygen is working at 6 liters per minute, his coloration is flushed and his respirations are 8 per minute. What ought to the nurse do first? A) Acquire a 12-lead EKG B) Place shopper in excessive Fowler’s place C) Decrease the oxygen charge D) Take baseline important indicators Decrease the oxygen charge 41. A 4 year-old has been hospitalized for twenty-four hours with skeletal traction for therapy of a fracture of the correct femur. The nurse finds that the kid is now crying and the correct foot is pale with the absence of a pulse. What ought to the nurse do first? * A) Notify the well being care supplier B) Readjust the traction C) Administer the ordered prn medicine D) Reassess the foot in fifteen minutes Notify the well being care supplier 42. The nurse is assessing a shopper 2 hours postoperatively after a femoral popliteal bypass. The higher leg dressing turns into saturated with blood. The nurse’s first motion must be to A) Wrap the leg with elastic bandages B) Apply stress on the bleeding website C) Reinforce the dressing and elevate the leg D) Take away the dressings and re-dress the incision Reinforce the dressing and elevate the leg 43. A shopper is receiving exterior beam radiation to the mediastinum for therapy of bronchial most cancers. Which of the next ought to take precedence in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Pores and skin irritation Overview Data: Leukopenia 44. A shopper has a chest tube in place following a left decrease lobectomy inserted after a stab wound to the chest. When repositioning the shopper, the nurse notices 200 cc of darkish, purple fluid flows into the gathering chamber of the chest drain. What’s the most applicable nursing motion? A) Clamp the chest tube B) Name the surgeon instantly C) Put together for blood transfusion D) Proceed to observe the speed of drainage Proceed to observe the speed of drainage 45. A shopper has returned from a cardiac catheterization. Which one of many following assessments would point out the shopper is experiencing a complication from the process? A) Elevated blood stress B) Elevated coronary heart charge C) Lack of pulse within the extremity D) Decreased urine output Lack of pulse within the extremity 46. A 60 year-old male shopper had a hernia restore in an outpatient surgical procedure clinic. He’s awake and alert, however has not been capable of void since he returned from surgical procedure 6 hours in the past. He obtained 1000 mL of IV fluid. Which motion can be most probably to assist him void? A) Have him drink a number of glasses of water B) Crede’ the bladder from the underside to the highest C) Help him to face by the facet of the mattress to void D) Wait 2 hours and have him attempt to void once more Help him to face by the facet of the mattress to void 47. The nurse is caring for a shopper who requires a mechanical ventilator for respiratory. The excessive stress alarm goes off on the ventilator. What’s the first motion the nurse ought to carry out? A) Disconnect the shopper from the ventilator and use a guide resuscitation bag B) Carry out a fast evaluation of the shopper’s situation C) Name the respiratory therapist for assist D) Press the alarm re-set button on the ventilator Carry out a fast evaluation of the shopper”s situation 48. The nurse is making ready a shopper who will endure a myelogram. Which of the next statements by the shopper signifies a contraindication for this take a look at? A) “I am unable to lie in 1 place for greater than thirty minutes.” B) “I’m allergic to shrimp.” C) “I endure from claustrophobia.” D) “I developed a extreme headache after a spinal faucet.” “I’m allergic to shrimp.” 49. The well being care supplier order reads “aspirate nasogastric feeding (NG) tuber each 4 hours and verify pH of aspirate.” The pH of the aspirate is 10. Which motion ought to the nurse take? A) Maintain the tube feeding and notify the supplier B) Administer the tube feeding as scheduled C) Irrigate the tube with food plan cola soda D) Apply intermittent suction to the feeding tube Maintain the tube feeding and notify the supplier 50. To forestall pointless hypoxia throughout suctioning of a tracheostomy, the nurse should A) Apply suction for not more than 10 seconds B) Keep sterile method C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a round movement Making use of suction for greater than 10 seconds 51. An antibiotic IM injection for a 2 year-old youngster is ordered. The whole quantity of the injection equals 2.0 ml The right motion is to A) administer the medicine in 2 separate injections B) give the medicine within the dorsal gluteal website C) name to get a smaller quantity ordered D) verify with pharmacy for a liquid type of the medicine skip administer the medicine in 2 separate injections 52. The nurse receives an order to offer a shopper iron by deep injection. The nurse know that the explanation for this route is to A) improve absorption of the medicine B) be certain that your entire dose of medicine is given C) present extra even distribution of the drug D) forestall the drug from tissue irritation Skip forestall the drug from tissue irritation 53. A shopper with coronary heart failure has Lanoxin (digoxin) ordered. What would the nurse anticipate finding when evaluating for the therapeutic effectiveness of this drug? A) diaphoresis with decreased urinary output B) elevated coronary heart charge with improve respirations C) improved respiratory standing and elevated urinary output D) decreased chest ache and decreased blood stress improved respiratory standing and elevated urinary output 54. Whereas offering house care to a shopper with congestive coronary heart failure, the nurse is requested how lengthy diuretics should be taken. What’s the nurse’s finest response? A) ”As you urinate extra, you’ll need much less medicine to regulate fluid.” B) ”You’ll have to take this medicine for a few 12 months.” C) ”The medicine should be continued so the fluid downside is managed.” D) ”Please speak to your well being care supplier about medicines and coverings.” “The medicine should be continued so the fluid downside is managed.” 55. A shopper is being discharged with a prescription for chlorpromazine (Thorazine). Earlier than leaving for house, which of those findings ought to the nurse train the shopper to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Stomach ache, nausea, diarrhea D) Dsypnea, nasal congestion Sore throat, fever 56. A shopper is recovering from a hip alternative and is taking Tylenol #3 each 3 hours for ache. In checking the shopper, which discovering suggests a facet impact of the analgesic? A) Bruising on the operative website B) Elevated coronary heart charge C) Decreased platelet depend D) No bowel motion for 3 days Skip No bowel motion for 3 days 57. A shopper is being maintained on heparin remedy for deep vein thrombosis. The nurse should intently monitor which of the next laboratory values? A) Bleeding time B) Platelet depend C) Activated PTT D) Clotting time Activated PTT 58. A shopper with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medicines. Which nursing motion is suitable? A) Pulverize all medicines to a powdery situation B) Squeeze the tube earlier than utilizing it to interrupt up stagnant liquids C) Cleanse the pores and skin across the tube every day with hydrogen peroxide D) Flush adequately with water earlier than and after utilizing the tube Skip Flush adequately with water earlier than and after utilizing the tube 59. The nurse has given discharge directions to oldsters of a kid on phenytoin (Dilantin). Which of the next statements means that the educating was efficient? A) ”We’ll name the well being care supplier if the kid develops zits.” B) ”Our youngster ought to brush and floss fastidiously after each meal.” C) ”We’ll skip the subsequent dose if vomiting or fever happen.” D) ”When our youngster is seizure-free for six months, we are able to cease the medicine.” “Our youngster ought to brush and floss fastidiously after each meal.” 60. Though non steroidal anti-inflammatory medicine resembling ibuprofen (Motrin) are useful in managing arthritis ache, the nurse ought to warning shoppers about which of the next widespread unintended effects? A) Urinary incontinence B) Constipation C) Nystagmus D) Occult bleeding Occult bleeding 61. The nurse is caring for a shopper with scientific melancholy who’s receiving a MAO inhibitor. When offering directions about precautions with this medicine, which motion ought to the nurse stress to the shopper as vital? A) Keep away from chocolate and cheese B) Take frequent naps C) Take the medicine with milk D) Keep away from strolling with out help Keep away from chocolate and cheese 62. A dad or mum asks the college nurse the way to get rid of lice from their youngster. What’s the most applicable response by the nurse? A) Minimize the kid’s hair quick to take away the nits B) Apply heat soaks to the pinnacle twice every day C) Wash the kid’s linen and clothes in a bleach answer D) Utility of pediculicides Utility of pediculicides 63. The nurse is educating a shopper about precautions with Coumadin remedy. The shopper must be instructed to keep away from which over-the-counter medicine? A) Non-steroidal anti-inflammatory medicine B) Cough medicines with guaifenesin C) Histamine blockers D) Laxatives containing magnesium salts Non-steroidal anti-inflammatory medicine 64. A shopper identified with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medicine spares elimination of which factor? A) Sodium B) Potassium C) Phosphate D) Albumin Potassium 65. The nurse is caring for a shopper receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What’s the first motion the nurse ought to take? A) Cease the infusion B) Gradual the speed of infusion C) Take important indicators and observe for additional deterioration D) Administer Benadryl and proceed the infusion Cease the infusion 66. Discharge directions for a shopper taking alprazolam (Xanax) ought to embody which of the next? A) Sedative hypnotics are efficient analgesics B) Sudden cessation of alprazolam (Xanax) may cause rebound insomnia and nightmares C) Caffeine drinks can improve the impact of sedative hypnotics D) Avoidance of extreme train and excessive temperature is really useful Sudden cessation of alprazolam 67. A shopper has obtained 2 items of entire blood in the present day following an episode of GI bleeding. Which of the next laboratory experiences would the nurse monitor most intently? A) Bleeding time B) Hemoglobin and hematocrit C) White blood cells D) Platelets Hemoglobin and hematocrit 68. A shopper is receiving intravenous heparin remedy. What medicine ought to the nurse have out there within the occasion of an overdose of heparin? A) Protamine B) Amicar C) Imferon D) Diltiazem Protamine . Protamine binds heparin making it ineffective. 69. The nurse has been educating a shopper with Insulin Dependent Diabetes Mellitus. Which assertion by the shopper signifies a necessity for additional educating? A) “I exploit a sliding scale to regulate common insulin to my sugar degree.” B) “Since my eyesight is so dangerous, I ask the nurse to fill a number of syringes.” C) “I hold my common insulin bottle within the fridge.” D) “I all the time be sure that to shake the NPH bottle exhausting to combine it properly.” “I all the time be sure that to shake the NPH bottle exhausting to combine it properly.” 70. Why is it vital for the nurse to observe blood stress in shoppers receiving antipsychotic medicine? A) Orthostatic hypotension is a typical facet impact B) Most antipsychotic medicine trigger elevated blood stress C) This gives data on the quantity of sodium allowed within the food plan D) It’ll point out the necessity to institute anti parkinsonian medicine Orthostatic hypotension is a typical facet impact 71. The nurse is educating the shopper to pick meals wealthy in potassium to assist forestall digitalis toxicity. Which selection signifies the shopper understands dietary wants? A) Three apricots B) Medium banana C) Naval orange D) Baked potato Baked potato. 72. An 86 year-old nursing house resident who has decreased psychological standing is hospitalized with pneumonic infiltrates in the correct decrease lobe. When the nurse assists the shopper with a transparent liquid food plan, the shopper begins to cough. What ought to the nurse do subsequent? A) Add a thickening agent to the fluids B) Test the shopper’s gag reflex C) Feed the shopper solely strong meals D) Enhance the speed of intravenous fluids Test the shopper’s gag reflex 73. The nurse is planning take care of a shopper with a CVA. Which of the next measures deliberate by the nurse can be only in stopping pores and skin breakdown? A) Place shopper within the wheelchair for 4 hours every day B) Pad the bony prominence C) Reposition each two hours D) Therapeutic massage reddened bony prominence Reposition each two hours 74. A nurse is assessing a number of shoppers in a long run well being care facility. Which shopper is at highest danger for improvement of decubitus ulcers? A) A 79 year-old malnourished shopper on mattress relaxation B) An overweight shopper who makes use of a wheelchair C) A shopper who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic shopper A 79 year-old malnourished shopper on mattress relaxation 75. Constipation is likely one of the most frequent complaints of elders. When assessing this downside, which motion must be the nurse’s precedence? A) Acquire a whole blood depend B) Acquire a well being and dietary historical past C) Confer with a supplier for a bodily examination D) Measure top and weight Acquire a well being and dietary historical past 76. After a shopper has an enteral feeding tube inserted, probably the most correct methodology for verification of placement is A) Stomach x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents Stomach x-ray 77. A shopper was simply taken off the ventilator after surgical procedure and has a nasogastric tube draining bile coloured liquids. Which nursing measure will present probably the most consolation to the shopper? A) Enable the shopper to soften ice chips within the mouth B) Present mints to freshen the breath C) Carry out frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs Carry out frequent oral care with a tooth sponge 78. The nurse is instructing a 65 year-old feminine shopper identified with osteoporosis. Crucial instruction relating to train can be to A) Train doing weight bearing actions B) Train to scale back weight C) Keep away from train actions that improve the danger of fracture D) Train to strengthen muscle tissues and thereby shield bones Train doing weight bearing actions 79. The nurse has been educating a shopper with congestive coronary heart failure about correct diet. The collection of which lunch signifies the shopper has discovered about sodium restriction? A) Cheese sandwich with a glass of two% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream Sliced turkey sandwich and canned pineapple 80. Which mattress place is most well-liked to be used with a shopper in an prolonged care facility on falls danger prevention protocol? A) All 4 facet rails up, wheels locked, mattress closest to door B) Decrease facet rails up, mattress dealing with doorway C) Knees bent, head barely elevated, mattress in lowest place D) Mattress in lowest place, wheels locked, place mattress towards wall Mattress in lowest place, wheels locked, place mattress towards wall 81. When administering enteral feeding to a shopper by way of a jejunostomy tube, the nurse ought to administer the components A) Each 4 to 6 hours B) Constantly C) In a bolus D) Each hour Constantly 82. The nurse is educating an 87 year-old shopper strategies for sustaining common bowel actions. The nurse would warning the shopper to AVOID A) Glycerine suppositories B) Fiber dietary supplements C) Laxatives D) Stool softeners Laxatives 83. A shopper with diarrhea ought to keep away from which of the next? A) Orange juice B) Tuna C) Eggs D) Macaroni Orange juice 84. Which assertion finest describes the results of immobility in youngsters? A) Immobility prevents the development of language and high quality motor improvement B) Immobility in youngsters has related bodily results to these present in adults C) Kids are extra prone to the results of immobility than are adults D) Kids are more likely to have extended immobility with subsequent problems Immobility in youngsters has related bodily results to these present in adults 85. A nurse is offering care to a 63 year-old shopper with pneumonia. Which intervention promotes the shopper’s consolation? A) Enhance oral fluid consumption B) Encourage visits from household and pals C) Hold conversations quick D) Monitor important indicators continuously Hold conversations quick 86. After a myocardial infarction, a shopper is positioned on a sodium restricted food plan. When the nurse is educating the shopper in regards to the food plan, which meal plan can be probably the most applicable A) 3 oz. broiled fish, 1 baked potato, . cup canned beets, 1 orange, and milk B) 3 oz. canned salmon, recent broccoli, 1 biscuit, tea, and 1 apple C) A bologna sandwich, recent eggplant, 2 ouncesfresh fruit, tea, and apple juice D) 3 oz. turkey, 1 recent candy potato, 1/2 cup recent inexperienced beans, milk, and 1 orange 3 oz. turkey, 1 recent candy potato, 1/2 cup recent inexperienced beans, milk, and 1 orange 87. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings embody reasonable edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most applicable? A) Decreased carbohydrates and fats B) Decreased sodium and potassium C) Elevated potassium and protein D) Elevated sodium and fluids Decreased sodium and potassium 88. What nursing evaluation of a paralyzed shopper would point out the possible presence of a fecal impaction? A) Presence of blood in stools B) Oozing liquid stool C) Steady rumbling flatulence D) Absence of bowel actions Oozing liquid stool 89. A shopper in a long run care facility complains of ache. The nurse collects knowledge in regards to the shopper’s ache. Step one in ache evaluation is for the nurse to A) have the shopper determine coping strategies B) get the outline of the situation and depth of the ache C) settle for the shopper’s report of ache D) decide the shopper’s standing of ache Settle for the shopper”s report of ache 90. An 85 year-old shopper complains of generalized muscle aches and pains. The primary motion by the nurse must be A) Assess the severity and site of the ache B) Acquire an order for an analgesic C) Reassure him that this isn’t uncommon for his age D) Encourage him to extend his exercise Assess the severity and site of the ache 91. A 20 year-old shopper has an contaminated leg wound from a bike accident, and the shopper has returned house from the hospital. The shopper is to maintain the affected leg elevated and is on contact precautions. The shopper desires to know if guests can come. The suitable response from the house well being nurse is that: A) Guests should put on a masks and a robe B) There are not any particular necessities for guests of shoppers on contact precautions C) Guests ought to wash their palms earlier than and after touching the shopper D) Guests Guests ought to wash their palms earlier than and after touching the shopper 92. A baby is admitted to the pediatric unit with a analysis of suspected meningococcal meningitis. Which admission orders ought to the nurse do first? A) Institute seizure precautions B) Monitor neurologic standing each hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h Place in respiratory/secretion precautions 93. Which of those nursing diagnoses of 4 aged shoppers would place 1 shopper on the biggest danger for falls? A) Sensory perceptual alterations associated to decreased imaginative and prescient B) Alteration in mobility associated to fatigue C) Impaired fuel trade associated to retained secretions D) Altered patterns of urinary elimination associated to nocturia Altered patterns of urinary elimination associated to nocturia 94. A nurse who’s reassigned to the emergency division wants to grasp that gastric lavage is a precedence during which scenario? A) An toddler who has been recognized to have botulism B) A toddler who ate various ibuprofen tablets C) A preschooler who swallowed powdered plant meals D) A faculty aged youngster who took a handful of nutritional vitamins An toddler who has been recognized to have botulism 95. A newly admitted grownup shopper has a analysis of hepatitis A. The cost nurse ought to reinforce to the employees members that probably the most vital routine an infection management technique, along with hand washing, to be applied is which of those? A) Apply applicable indicators inside and outside the room B) Apply a masks with a defend if there’s a danger of fluid splash C) Put on a robe to alter dirty linens from incontinence D) Have gloves on whereas dealing with bedpans with feces Have gloves on whereas dealing with bedpans with feces 96. Which of those shoppers with related lab experiences is a precedence for the nurse to report back to the general public well being division throughout the subsequent 24 hours? A) An toddler with a constructive tradition of stool for Shigella B) An aged manufacturing unit employee with a lab report that’s constructive for acid-fast bacillus smear C) A younger grownup business pilot with a constructive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a historical past of varicella-zoster virus and with crops of vesicles on an erythematous base that seem on the pores and skin An aged manufacturing unit employee with a lab report that’s constructive for acid-fast bacillus smear 97. A shopper is identified with methicillin resistant staphylococcus aureus pneumonia. What kind of isolation is most applicable for this shopper? A) Reverse B) Airborne C) Commonplace precautions D) Contact Contact 98. The college nurse is educating the school the best strategies to forestall the unfold of lice within the college. The data that will be most vital to incorporate can be which of those statements? A) ”The therapy requires reapplication in 8 to 10 days.” B) ”Bedding and clothes could be boiled or steamed.” C) Kids are to not share hats, scarves and combs. D) Nit combs are essential to comb out nits. “Kids are to not share hats, scarves and combs.” 99. Throughout the care of a shopper with a salmonella an infection, the first nursing intervention to restrict transmission is which of those approaches? A) Wash palms totally earlier than and after shopper contact B) Put on gloves when in touch with physique secretions C) Double glove when in touch with feces or vomitus D) Put on gloves when disposing of contaminated linens Wash palms totally earlier than and after shopper contact 100. A nurse is reinforcing educating with a shopper about compromised host precautions. The shopper is receiving filgrastim (Neupogen) for neutropenia. The collection of which lunch suggests the shopper has discovered about mandatory dietary modifications? A) grilled hen sandwich and skim milk B) roast beef, mashed potatoes, and inexperienced beans C) peanut butter sandwich, banana, and iced tea D) barbecue beef, baked beans, and cole slaw roast beef, mashed potatoes, and inexperienced beans 101. After an explosion at a manufacturing unit one of many staff approaches the nurse and says “I’m an unlicensed assistive personnel (UAP) on the native hospital.” Which of those duties ought to the nurse assign to this employee who desires to assist in the course of the care of the wounded staff? A) Get temperatures B) Take blood stress C) Palpate pulses D) Test alertness Palpate pulses 102. Which of those shoppers would the nurse suggest to maintain within the hospital throughout an inside catastrophe on the company? A) An adolescent identified with sepsis 7 days in the past with important indicators maintained inside low regular B) A middle-aged girl documented to have had an uncomplicated myocardial infarction 4 days in the past C) An aged man admitted 2 days in the past with an acute exacerbation of ulcerative colitis D) A younger grownup within the second day of therapy for an overdose of acetometaphen A younger grownup within the second day of therapy for an overdose of acetometaphen 103. The mom of a toddler who’s being handled for pesticide poisoning asks: “Why is activated charcoal used? What does it do?” What’s the nurse’s finest response? A) ”Activated charcoal decreases the systemic absorption of the poison from the abdomen.” B) ”The charcoal absorbs the poison and types a compound that does not harm your youngster.” C) ”This substance helps to get the poison out of the physique by the gastrointestinal system.” D) ”The motion could bind or inactivate the toxins or irritants which might be ingested by youngsters or adults.” “The charcoal absorbs the poison and types a compound that does’t harm your youngster.” 104. The nurse is to manage a brand new medicine to a shopper. Which actions are in the most effective curiosity of the shopper? Confirm the order for the medicine. Previous to giving the medicine the nurse ought to say A) ”Please state your title?” Upon coming into the room the nurse ought to ask: B) ”What’s your title? What allergy symptoms do you’ve got?” then verify the shopper’s title band and allergy band Because the room is entered say C) “What’s your title?” then verify the shopper’s title band Confirm the shopper’s allergy symptoms on the admission sheet and order. D) “Confirm the shopper’s title on the title plate outdoors the room then because the nurse enters the room ask the shopper “What’s your first, center and final title?” Upon coming into the room the nurse ought to ask: “What’s your title? What allergy symptoms do you’ve got?” then verify the shopper”s title band and allergy band 105. A number of shoppers are admitted to an grownup medical unit. The nurse would guarantee airborne precautions for a shopper with which medical situation? A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) B) A constructive purified protein by-product with an irregular chest x-ray C) A tentative analysis of viral pneumonia with productive brown sputum D) Superior carcinoma of the lung with hemoptasis A constructive purified protein by-product with an irregular chest xray 106. A shopper is scheduled to obtain an oral answer of radioactive iodine (131I). So as to cut back hazards, the precedence data for the nurse to incorporate in the course of the directions to the shopper is which of those statements? A) Within the preliminary 48 hours keep away from contact with youngsters and pregnant girls, and after urination or defecation flush the commode twice. B) Use disposable utensils for two days and if vomiting happens inside 10 hours of the dose, accomplish that in the bathroom and flush it twice. C) Your loved ones can use the identical lavatory that you just use with none particular precautions. D) Drink loads of water and empty your bladder usually in the course of the preliminary 3 days of remedy. “Within the preliminary 48 hours keep away from contact with youngsters and pregnant girls, and after urination or defecation flush the commode twice.” 107. Which method is one of the simplest ways to forestall infections when offering care to shoppers within the house setting? A) Hand washing earlier than and after examination of shoppers B) Carrying non powdered latex free gloves to look at the shopper C) Utilizing a barrier between the shopper’s furnishings and the nurse’s bag D) Carrying a masks with a defend throughout any eye/mouth/nostril examination Hand washing 108. A ten year-old youngster has a historical past of epilepsy with tonic-clonic seizures. The college nurse ought to instruct the classroom instructor that if the kid experiences a seizure within the classroom, crucial motion in the course of the seizure can be to A) Transfer any chairs or desks at the very least 3 ft away from the kid B) Be aware the sequence of actions with the time lapse of the occasion C) Present privateness as a lot as potential to attenuate preventing the opposite youngsters D) Place the palms or a folded blanket underneath the pinnacle of the kid Place the palms or a folded blanket underneath the pinnacle of the kid 109. A mom calls the hospital sizzling line and is linked to the triage nurse. The mom proclaims: “I discovered my youngster with odd stuff coming from the mouth and an unmarked bottle close by.” Which of those feedback can be the most effective for the nurse to ask the mom to find out if the kid has swallowed a corrosive substance? A) Ask the kid if the mouth is burning or throat ache is current B) Take the kid’s pulse on the wrist and see if the kid is has hassle respiratory mendacity flat. C) What coloration is the kid’s lips and nails and has the kid voided in the present day? D) Has the kid had vomiting or diarrhea or abdomen cramps but? “Ask the kid if the mouth is burning or throat ache is current” 110. The nurse is assigned to a shopper newly identified with energetic tuberculosis. Which of those protocols can be a precedence for the nurse to implement? A) Have the shopper cough right into a tissue and dispose in a separate bag B) Instruct the shopper to cowl the mouth with a tissue when coughing C) Reinforce for all to scrub their palms earlier than and after coming into the room D) Place shopper in a unfavourable stress personal room and have all who enter the room use masks with shields Place shopper in a unfavourable stress personal room and have all who enter the room use masks with shields 111. The cost nurse is planning assignments on a medical unit. Which shopper must be assigned to the PN? A) Check a stool specimen for occult blood B) Help with the ambulation of a shopper with a chest tube C) Irrigate and redress a leg wound D) Admit a shopper from the emergency room Irrigate and redress a leg wound 112. When assessing a shopper, it is crucial for the nurse to be told about cultural points associated to the shopper’s background as a result of A) Regular patterns of habits could also be labeled as deviant, immoral, or insane B) The which means of the shopper’s habits could be derived from standard knowledge C) Private values will information the interplay between individuals from 2 cultures D) The nurse ought to depend on her data of various developmental psychological phases Regular patterns of habits could also be labeled as deviant, immoral, or insane 113. The nurse is liable for a number of aged shoppers, together with a shopper on mattress relaxation with a pores and skin tear and hematoma from a fall 2 days in the past. What’s the finest care task for this shopper? A) Assign an RN to supply whole care of the shopper B) Assign a nursing assistant to assist the shopper with self-care actions C) Delegate full care to an unlicensed assistive personnel D) Supervise a nursing assistant for skincare Supervise a nursing assistant for skincare. 114. The nursing scholar is discussing with a preceptor the delegation of duties to an unlicensed assistive personnel (UAP). Which duties, delegated to a UAP, signifies the scholar wants additional educating in regards to the delegation course of? A) Help a shopper put up cerebral vascular accident to ambulate B) Feed a 2 year-old in balanced skeletal traction C) Take care of a shopper with discharge orders D) Gather a sputum specimen for acid quick bacillus Take care of a shopper with discharge orders 115. After working with a really demanding shopper, an unlicensed assistive personnel (UAP) tells the nurse, “I’ve had it with that shopper. I simply can’t do something that pleases him. I’m not entering into there once more.” The nurse ought to reply by saying A) ”He has a variety of issues. It’s good to have endurance with him.” B) ”I’ll speak with him and take a look at to determine what to do.” C) ”He’s scared and taking it out on you. Let’s speak to determine what to do.” D) ”Ignore him and get the remainder of your work completed. Another person can handle him for the remainder of the day.” “He’s scared and taking it out on you. Let”s speak to determine what to do.” 116. A shopper with a analysis of bipolar dysfunction has been referred to a neighborhood boarding house for consideration for placement. The social employee telephoned the hospital unit for details about the shopper’s psychological standing and adjustment. The suitable response of the nurse must be which of those statements? A) I’m sorry. Referral data can solely be supplied by the shopper’s well being care suppliers. B) “I can by no means give any data out by phone. How do I do know who you might be?” C) Since it is a referral, I can provide the this data. D) I have to get the shopper’s written consent earlier than I launch any data to you. I have to get the shopper’s written consent earlier than I launch any data to you. 117. A shopper is admitted with a analysis of schizophrenia. The shopper refuses to take medicine and states “I don’t assume I would like these medicines. They make me too sleepy and drowsy. I insist that you just clarify their use and unintended effects.” The nurse ought to perceive that A) A referral is required to the psychiatrist who’s to supply the shopper with solutions B) The shopper has a proper to know in regards to the prescribed medicines C) Such training is an impartial resolution of the person nurse whether or not or to not train shoppers about their medicines D) Shoppers with schizophrenia are at a better danger of psychosocial problems once they find out about their medicine unintended effects The shopper has a proper to know in regards to the prescribed medicines 118. Which assertion by the nurse is suitable when asking an unlicensed assistive personnel (UAP) to help a 69 year-old surgical shopper to ambulate for the primary time? A) ”Have the shopper sit on the facet of the mattress for at the very least 2 minutes earlier than serving to him stand.” B) ”If the shopper is dizzy on standing, ask him to take some deep breaths.” C) ”Help the shopper to the lavatory at the very least twice on this shift.” D) ”After you help him to the chair, let me understand how he feels.” “Have the shopper sit on the facet of the mattress for at the very least 2 minutes earlier than serving to him stand.” 119. The nurse receives a report on an older grownup shopper with center stage dementia. What data suggests the nurse ought to do speedy comply with up relatively than delegate care to the nursing assistant? The shopper A) Has had a change in respiratory charge by a rise of two breaths B) Has had a change in coronary heart charge by a rise of 10 beats C) Was minimally aware of voice and contact D) Has had a blood stress change by a drop in 8 mmHg systolic Was minimally aware of voice and contact 120. A shopper tells the nurse, “I’ve one thing crucial to let you know when you promise to not inform.” The most effective response by the nurse is A) ”I have to doc and report any data.” B) ”I can’t make such a promise.” C) ”That will depend on what you inform me.” D) ”I have to report the whole lot to the therapy crew.” “I can’t make such a promise.” 121. Which process may very well be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A) Be with a shopper who self-administers insulin B) Cleanse and gown a small decubitus ulcer C) Monitor a shopper’s response to passive vary of movement workout routines D) Apply and take care of a shopper’s rectal pouch Apply and take care of a shopper”s rectal pouch 122. A shopper asks the nurse to name the police and states: “I have to report that I’m being abused by a nurse.” The nurse ought to first A) Concentrate on actuality orientation to put and particular person B) Help with the report of the shopper’s criticism to the police C) Acquire extra particulars of the shopper’s declare of abuse D) Doc the assertion on the shopper’s chart with a report back to the supervisor Acquire extra particulars of the shopper’s declare of abuse 123. A nurse from the maternity unit is floated to the crucial care unit due to employees scarcity on the night shift. Which shopper can be applicable to assign to this nurse? A shopper with A) A Dopamine drip IV with important indicators monitored each 5 minutes B) A myocardial infarction that’s free from ache and dysrhythmias C) A tracheotomy of 24 hours in some respiratory misery D) A pacemaker inserted this morning with intermittent seize A myocardial infarction that’s free from ache and dysrhythmias 124. An unlicensed assistive personnel (UAP), who normally works on a surgical unit is assigned to drift to a pediatric unit. Which query by the cost nurse can be most applicable when making delegation choices? A) ”How lengthy have you ever been a UAP and what items you’ve got labored on?” B) ”What kind of care do you give on the surgical unit and what ages of shoppers?” C) “What’s your consolation degree in caring for kids and at what ages?” D) ”Have you ever reviewed the listing of anticipated abilities you may want on this unit?” “Have you ever reviewed the listing of anticipated abilities you may want on this unit?” 125. A shopper continuously admitted to the locked psychiatric unit repeatedly compliments and invitations one of many nurses to exit on a date. The nurse’s response must be to A) Ask to not be assigned to this shopper or to work on one other unit B) Inform the shopper that such habits is inappropriate C) Inform the shopper that hospital coverage prohibits employees thus far shoppers D) Talk about the boundaries of the therapeutic relationship with the shopper Talk about the boundaries of the connection with the shopper 126. A shopper has a nasogastric tube after colon surgical procedure. Which one among these duties could be safely delegated to an unlicensed assistive personnel (UAP)? A) To look at the sort and quantity of nasogastric tube drainage B) Monitor the shopper for nausea or different problems C) Irrigate the nasogastric tube with the ordered irrigate D) Carry out nostril and mouth care Carry out nostril and mouth care 127. The nurse is caring for a 69 year-old shopper with a analysis of hyperglycemia. Which duties may the nurse delegate to the unlicensed assistive personnel (UAP)? A) Check blood sugar each 2 hours by accu verify B) Overview with household and shopper indicators of hyperglycemia C) Monitor for psychological standing modifications D) Test pores and skin situation of decrease extremities Overview Data: Check blood sugar each 2 hours by accucheck 128. A nurse is working with one licensed sensible nurse (PN), a scholar nurse and an unlicensed assistive personnel (UAP). Which newly admitted shoppers can be most applicable to assign to the UAP? A) A 76-year-old shopper with extreme melancholy B) A middle-aged shopper with an obsessive compulsive dysfunction C) A adolescent with dehydration and anorexia D) A younger grownup who’s a heroin addict in withdrawal with hallucinations A middle-aged shopper with an obsessive compulsive dysfunction 129. The unlicensed assistive personnel (UAP) experiences a sudden improve in temperature to 101 levels F for a put up surgical shopper. The nurse checks on the shopper’s situation and observes a cup of steaming espresso on the bedside. What directions are applicable to offer to the UAP? A) Encourage oral fluids for the temperature elevation B) Test temperature quarter-hour after sizzling liquids are taken C) Ask the shopper to drink solely chilly water and juices D) Chart this temperature elevation on the stream sheet Test temperature quarter-hour after sizzling liquids are taken 130. A shopper constantly calls out to the nursing employees when anybody passes the shopper’s door and asks them to do one thing within the room. The most effective response by the cost nurse can be to A) Hold the shopper’s room door cracked to attenuate the distractions B) Assign 1 of the nursing employees to go to the shopper repeatedly C) Reassure the shopper that 1 employees particular person will verify continuously if the shopper wants something D) Organize for every employees member to enter the shopper’s room to verify on wants each hour on the hour Assign 1 of the nursing employees to go to the shopper repeatedly 131. A shopper with a brand new analysis of diabetes mellitus is referred for house care. A member of the family current expresses concern that the shopper appears depressed. The nurse ought to initially focus evaluation by utilizing which method? A) The outcomes of a standardized instrument that measures melancholy B) Remark of have an effect on and habits C) Inquiry about use of alcohol D) Household historical past of emotional issues or psychological sickness Remark of have an effect on and habits 132. A mom with a Roman Catholic perception has given beginning in an ambulance on the best way to the hospital. The neonate is in very crucial situation with little expectation of surviving the journey to the hospital. Which of those requests ought to the nurse within the ambulance anticipate and be ready to do? A) The refusal of any therapy for self and the neonate till she talks to a reader B) The location of a rosary necklace across the neonate’s neck and to not take away it until completely mandatory C) Organize for a church elder to be on the emergency division when the ambulance arrives so a “laying on palms” could be completed D) Pour fluid over the brow backwards in direction of the again of the pinnacle and say “I baptize you within the title of the daddy, the son and the holy spirit. Amen.” Pour fluid over the brow backwards in direction of the again of the pinnacle and say “I baptize you within the title of the daddy, the son and the holy spirit. Amen.” 133. An American Indian chief visits his new child son and performs a conventional ceremony that includes feathers and chanting. The attending nurse tells a colleague “I ponder if he has any thought how ridiculous he appears to be like — he is a grown man!” The nurse’s response is an instance of A) Discrimination B) Stereotyping C) Ethnocentrism D) Prejudice Prejudice 134. A shopper expresses anger when the decision gentle isn’t answered inside 5 minutes. The shopper demanded a blanket. The most effective response for the nurse to make is A) “I apologize for the delay. I used to be concerned in an emergency.” B) “Let’s speak. Why are you upset about this?” C) “I’m shocked that you’re upset. The request may have waited a number of extra minutes.” D) “I see that is irritating for you. I’ve a couple of minutes so let’s speak.” “I see that is irritating for you. I’ve a couple of minutes so let”s speak.” 135. An aged shopper who lives in a retirement neighborhood is admitted with these behaviors as reported by the daughter: absence within the every day senior group exercise, lacking the weekly card video games, a change in calling the daughter from every day to as soon as per week, and the shopper’s tomato backyard is overgrown with weeds. The nurse ought to assign this shopper to a room with which one among these shoppers? A) An adolescent who was admitted the day earlier than with acute situational melancholy B) A center aged one that has been on the unit for 72 hours with a dysthymia C) An aged one that was admitted 3 hours in the past with cycothymia D) A younger grownup who was admitted 24 hours in the past for cleansing A center aged one that has been on the unit for 72 hours with a dysthymia 136. A shopper identified with anorexia nervosa states after lunch, “I shouldn’t have eaten all of that sandwich, I don’t know why I ate it, I wasn’t hungry.” The shopper’s feedback point out that the shopper is probably going experiencing A) Guilt B) Bloating C) Anxiousness D) Concern Guilt 137. A 65-year-old Catholic Hispanic-Latino shopper with prostate most cancers adamantly refuses ache medicine as a result of the shopper believes that struggling is a part of life. The shopper states “everybody’s life is in God’s palms.” The subsequent motion for the nurse to take is to A) Report the scenario to the well being care supplier B) Talk about the scenario with the shopper’s household C) Ask the shopper if speaking with a priest can be desired D) Doc the scenario on the notes Ask the shopper if speaking with a priest can be desired 138. A teenage feminine is admitted with the analysis of anorexia nervosa. Upon admission, the nurse finds a bottle of varied tablets within the shopper’s drawer. The shopper tells the nurse that they’re antacids for abdomen pains. The most effective response by the nurse can be A) “These tablets aren’t antacids since they’re all completely different.” B) “Some youngsters use tablets to shed pounds.” C) “Inform me about your week previous to being admitted.” D) “Are you taking tablets to alter your weight?” “Inform me about your week previous to being admitted.” 139. A shopper who has a perception primarily based in Hinduism is nearing loss of life. The nurse ought to plan for which motion? A) After loss of life a Hindu priest will pour water into the mouth of the shopper and tie a thread across the shopper’s wrist B) The elders could also be with the shopper in the course of the technique of the shopper dying and no final rites are given C) The household should be with the shopper in the course of the technique of dying and be the one ones to scrub the physique after loss of life D) The physique is ritually cleansed and burial is to be as quickly as potential after the loss of life happens After loss of life a Hindu priest will pour water into the mouth of the shopper and tie a thread across the shopper”s wrist 140. An explosion has occurred at a highschool for kids with particular wants and extreme developmental delays. One of many college students accompanied with a dad or mum is seen at a neighborhood well being heart a day later. After the preliminary evaluation the nurse concludes that the scholar seems to be in a disaster state. Which of those interventions primarily based on disaster intervention rules is suitable to do subsequent? A) Assist the scholar to determine a particular downside B) Ask the dad or mum to determine the most important downside C) Ask the scholar to consider completely different options D) Study with the dad or mum a wide range of choices Ask the dad or mum to determine the most important downside 141. Which assertion made by a shopper to the admitting nurse means that the shopper is experiencing a manic episode? A) “I believe all youngsters ought to have their heads shaved.” B) “I’ve been restricted in thought and harmed.” C) “I’ve powers to get you no matter you would like, regardless of the price.” D) “I believe all of my contacts final week have tried to poison me.” Overview Data: “I’ve powers to get you no matter you would like, regardless of the price.” 142. A shopper says, “It is raining outdoors and it is raining in my coronary heart. Do you know that St. Patrick drove the snakes out of Eire? I’ve by no means been to Eire.” The nurse would doc this habits as A) Perseveration B) Circumstantiality C) Neologisms D) Flight of concepts Flight of concepts 143. Throughout the change-of-shift report the assigned nurse notes a Catholic shopper is scheduled to be admitted for the supply of a ninth youngster. Which remark said angrily to a colleague by this nurse signifies an angle of prejudice? A) “I ponder who’s paying for this journey to the hospital?” B) “I believe she must go to town hospital.” C) “All these individuals take pleasure in massive households!” D) “Does not she know there’s such a factor as contraception?” “Does not she know there”s such a factor as contraception?” 144. Which of those statements by the nurse displays the most effective use of therapeutic interplay methods? A) ”You look upset. Would you want to speak about it?” B) ”I’d prefer to know extra about your loved ones. Inform me about them.” C) ”I perceive that you just misplaced your associate. I do not assume I may go on if that occurred to me.” D) ”You look very unhappy. How lengthy have you ever been this fashion?” “You look upset. Would you want to speak about it?” 14