HESI EXIT RN EXAM V3 2022

Examination For HESI EXIT RN EXAM V3 2022

Obtain HESI EXIT VERSION 3 2021/2022 newest replace Examination Options GRADED A+ and extra Nursing Exams in PDF solely on Docsity!

HESI EXIT 2021/2022 VERSION 3 100% CORRECT QUESTIONS & ANSWERS The nurse is reviewing medical prescriptions for newly admitted shoppers. It will be a precedence for the nurse to observe up with the doctor if a shopper with (a) a potassium stage of 4.5mEq/L has Kayexalate (sodium polystyrene) prescribed (b) a Dilantin (phenytoin) stage of 8 mcg/ml is positioned on seizure precautions(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen) (d) sensitivity to Penicillin is prescribed Zithromax (azithromycin) The nurse ought to intervene if the nurse notes a employees member (a) acquiring a shoppers consent previous to their operative process after receiving Ativan (lorazepam) (b) inserting a shopper on the affected facet following surgical restore of a retinal detachment (c) dealing with a moist solid with the palms of the palms (d) utilizing a broad base of assist whereas transferring a shopper The neighborhood well being nurse is caring for the next shoppers. It will be a precedence for the nurse to provoke a multidisciplinary convention for the shopper who’s (a) 12 years previous with Autism who’s beginning a brand new faculty and just lately had a URI (higher respiratory tract an infection) (b) 16 years previous, has sort 1 Diabetes Mellitus, is unemployed and hada latest Hemoglobin Alc of 13% (Cc) 52 years previous, with Myasthenia Gravis, just lately prescribed Mestinon (pyridostigmine) and employed as a mail service (d) 70 years previous, has schizophrenia, lives alone and stories listening to non threatening voices. The nurse from the postpartum unit has been quickly assigned to the medical surgical unit. It will be most applicable to assign this nurse to the shopper who* (a) has returned from proper whole hip substitute surgical procedure 4 hours in the past (b) is being noticed for elevated intracranial stress 2 10. 11. 12. 13. The nurse is making ready a employees presentation on authorized and moral points in nursing. The nurse could be right to incorporate which of the next examples? (a) Placing a shopper in a geriatric chair with the lap tray in entrance of the shopper within the day room to observe tv is fake imprisonment (b) Telling a shopper that you’ll put in a feeding tube if the shopper doesn’t eat is an instance of battery (c) Telling a shopper with bipolar dysfunction who’s suicidal that they’ve a proper to refuse to take their medicines is an instance of malpractice (d) Inserting palms on a shopper who says “don’t contact me” is an instance of assault The nurse from the pediatric unit has been quickly assigned to the Emergency Division. It will be most applicable to assign that nurse to the shopper who* (a) stories epigastric ache that “looks like indigestion” (b) has again ache and a pulsating belly mass (c) is HIV+ reporting vomiting and diarrhea (d) presents with decrease belly ache and is six weeks pregnant 4 shoppers just lately returned to the unit following invasive diagnostic testing. The nurse ought to instantly intervene if one of many shoppers (a) stories blood tinged sputum following a bronchoscopy (b) has decreased belly girth following paracentesis (Cc) stories a headache following a lumbar puncture (d) is noticed flexing and increasing the legs two hours after cardiac catheterization The nurse is made conscious of the next conditions. The nurse ought to fi rst examine the shopper who (a) had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours after the indwelling catheter is eliminated (b) has cervical traction and is shifting the legs by fl exing and increasing the ft (c) has Alzheimer’s illness (stage 1) and was returned to the room after being discovered wandering within the hallway (d) has a historical past of partial seizures and is sitting within the mattress choosing on the clothes and smacking the lips 14. The nurse in a neighborhood well being clinic is speaking with the dad or mum of a kid with Celiac Illness. Which of the next statements would require follow-up by the 15. 16. 17. 18. nurse for added educating? (a) “This weekend we’re going to a seafood restaurant.” (b) “I can feed my youngster oatmeal and eggs for breakfast.” (c) “My youngster likes to eat rice and rooster for dinner.” (d) “Final night time we ate fi sh with corn for dinner.” The cost nurse is observing a Licensed Sensible Nurse (LPN) performing take care of assigned shoppers. Observe up shall be required if the LPN*: (a) assesses a shopper’s apical pulse earlier than administering Digoxin (lanoxin) (b) elevates the shopper’s stump on a pillow eight hours after amputation (c) dons a clear glove on the dominant hand earlier than tracheal suctioning (d) positions a shopper on the operative facet following a pneumonectomy The nurse at a well being promotion honest has taught a bunch of fogeys about automobile seat and seat belt security. Which of the next statements, if made by the dad or mum, would point out an accurate understanding of the data given? (a) “I’ll place my new child toddler in a rear going through automobile seat in the midst of the rear seat.” (b) “I’ll put on a lap seat belt excessive on my stomach since I’m 8 months pregnant.” (c) “I can use a front-facing automobile seat as soon as my child weighs 15 kilos.” (d) “I can enable my six-year-old to make use of a seat belt within the entrance passenger seat.” The nurse is caring for a shopper being handled for Vancomycin Resistant Enterococcus (VRE). The nurse ought to place the shopper on (a) contact precautions (b) droplet precautions (C) protecting precautions (d) airborne precautions The nurse is caring for a shopper with a Vancomycin Resistant Enterococcus (VRE) wound an infection. Which of the next actions could be applicable for the nurse to take? (a) Put on a particulate respirator masks when offering wound care (b) Instruct guests to not convey fl owers into the shopper’s room 7 The nurse ought to anticipate that the shopper will initially be prescribed (a) Illness-modifying rheumatic brokers (DMARDs) (b) Nonselective anti-infl ammatory medication (NSAIDs) 10 24, 25. 26. 27. 28. (c) Lengthy-term corticosteroids (d) Biologic Response Modifi ers The nurse is assessing a 2-month-old-infant at a properly child clinic. The nurse ought to anticipate the toddler ought to (a) roll from vulnerable to again (b) don’t have any head lag (c) smile socially (d) don’t have any tonic neck refl ex The nurse is educating a category on toddler vitamin. The nurse ought to instruct mother and father to introduce (a) fruit juices at 3 months (b) honey sweetened water at 6 months (c) pureed rooster at 7 months (d) entire milk at 9 months The nurse is caring for a 7-year-old who has thrombocytopenia and is on protecting precautions. Which of the next could be an applicable toy for the nurse to supply to the shopper? (a) Finger paints and paper (b) A rubber ball and bat (c) A board sport (d) A stuffed toy The nurse on a pediatric unit has been knowledgeable that the next shoppers are being admitted. The nurse ought to fi rst plan to evaluate the shopper who’s* (a) 2 years previous, has a temperature of 100.8 F and a blood stress of 68/44 (b) 4 years previous with a historical past of bronchial asthma and has a peak expiratory fl ow fee (PERF) of 81% (c) 5 years previous, has a fracture of the tibia and is reporting ache rated 7 on a ache scale of 0 (no ache) to 10 (extreme ache) (d) 7 years previous with ulcerative colitis and has had 15 blood tinged stools at this time The nurse is offering discharge directions to the mother and father of an toddler who has a 11 cleft lip. The nurse ought to instruct the mother and father to (a) place the toddler in a susceptible place after every feeding (b) encourage the mother and father to supply the toddler relaxation durations throughout feedings 12 (d) The Haemophilus Infl uenza Kind b (HIB) is given yearly to guard towards the fl u.” 33. The mom of an toddler tells the nurse that the child has not been tolerating feedings currently and she or he seen an olive-shaped mass within the toddler’s stomach. The nurse acknowledges that this could possibly be an anticipated fi nding if the toddler has (a) intussusception (b) Hirschsprung’s illness (Cc) umbilical hernia (d) pyloric stenosis 34, The nurse is educating a bunch of fogeys concerning the anticipated progress and growth of three-year-old youngsters. The nurse ought to embrace {that a} three-year-old ought to (a) discriminate between fantasy and actuality (b) trip a tricycle independently (Cc) have a vocabulary of seven,000 phrases (d) play in a bunch of two or three with one being the chief 35. The nurse and the nursing assistant are caring for a bunch of shoppers. Which of the next shopper care actions ought to the nurse assign to the nursing assistant? Choose all that apply. (a)____ reinforcing the dressing of a shopper who has a decubitus ulcer (b)____ monitoring the very important indicators of a shopper who had a myocardial infarction 12 hours in the past and is being transferred from the coronary care unit (c) administering a prescribed Fleet’s enema to a shopper who will endure a colonoscopy in two hours (d) inserting a shopper who had an above the knee amputation 24 hours in the past in a susceptible place (e)____assisting a shopper who had a colon resection 36 hours in the past to ambulate (f) _____ exhibiting a shopper who had a vaginal hysterectomy 36 hours in the past the right way to carry out perineal care 36. The nurse is caring for a shopper with Acquired immunodefi ciency syndrome (AIDS) 15 who was began on Zidovidine (AZT). It will be essential for the nurse to evaluate 16 37. 38. 39. 40. (a) blood ammonia serum (b) serum potassium (c) full blood rely (CBC) (d) serum uric acid The nurse is performing an belly evaluation. Point out the right sequence the nurse ought to use to carry out this evaluation. (a) percussion (b) palpation (c) auscultation (d) inspection Reply, The nurse has turn out to be conscious of the next shopper conditions. The nurse ought to fi rst assess the shopper who* (a) had acquired a unit of packed pink blood cells 4 hours in the past and is requesting a bedpan (b) had an belly hysterectomy yesterday and is reporting calf ache (c) has historical past of a number of sclerosis and is reporting diplopia (d) had a tonsillectomy three hours in the past and is reporting a sore throat The nurse is caring for a shopper who has been prescribed 1,000 ml of Ringer’s Lactate to infuse over 8 hours. The accessible intravenous set delivers 10 drops per milliliter. What number of drops per minute ought to the nurse set the intravenous controller to manage? Reply The first well being care supplier has prescribed an oral answer of Potassium Chloride (KCL) 20 mEq PO, QD. The drug accessible is Potassium Chloride 10 mEq/15ml. What number of ml ought to the nurse administer? Reply, 17 (a) inserting a shopper who had an above-the-knee amputation (AKA) 24 hours in the past in a susceptible place 20 49, 50. 51. 52. (b) holding the top of the mattress elevated for the shopper who had an supratentorial craniotomy 12 hours in the past (c) giving orange juice to a shopper who has a transparent liquid eating regimen prescribed (d) eradicating all liquids from the tray earlier than giving the tray to a shopper who has dumping syndrome The first well being care supplier has prescribed ampicillin (Omnipen) 0.5 GM PO Q6H to a 15 month previous toddler who weighs 22 kilos. The drug accessible is ampicillin suspension 250 mg/5 ml. The really helpful dosage is 50 mg/kg/ day each 6 to eight hours. The nurse ought to (a) name the first well being care supplier to report that the prescription exceeds the really helpful dosage (b) decide if the toddler has beforehand had a penicillin or a cephalosporin prescribed (Cc) give the toddler the ampicillin combined with applesauce (d) wait till the results of the throat tradition obtained one hour in the past is reported The nurse is instructing a category for folks of kids identified with sickle cell anemia. The nurse ought to instruct the mother and father to have the kids keep away from (A) publicity to sizzling water (b) different youngsters with infections (c) medicines containing aspirin (d) non – contact sports activities The nurse is assessing a 5-month-old toddler. The nurse ought to count on the toddler to (a) roll from stomach to again (b) sit with out assist (Cc) say ‘mama’ and ‘dada’ (d) favor use of 1 hand over the opposite The house well being care nurse is assigned to see 4 shoppers who all reside inside three miles of one another. The nurse ought to fi rst see the shopper who has (a) gastroesophageal refl ux illness (GERD) and is reporting a burning 21 belly ache that’s relieved by strolling (b) most cancers of the esophagus who has given away a favourite shirt because the final go to 22 57. 59. 60. (d) “I tried to carry out CPR to forestall my toddler from turning into unresponsive.” The nurse is caring for a shopper who’s ventilator dependent. The nurse is conscious that the excessive stress alarm may be sounded for varied causes. Choose all causes that would apply. (a)__ elevated bronchial secretions (b)____ the presence of an air leak (c) the presence of a kink within the tubing (d) the shopper stops respiration spontaneously (e)___acute bronchospasm (f) _____the shopper is biting the tube (g)____the ventilator tubing is disconnected . The nurse is caring for a shopper who has a brand new colostomy. The colostomy stoma is pink, moist and barely raised. The nurse ought to (a) decide if the shopper is allergic to the pores and skin barrier (b) apply petroleum jelly gauze across the stoma (c) doc the situation of the stoma (d) assess the shopper’s temperature The nurse has attended a employees growth convention on medical therapies for varied neurological issues. Which of the next statements if made by the nurse would require follow-up? (a) “Purchasers with Guillain-Barre’ syndrome (GBS) typically have plasmapheresis prescribed.” (b) “Myasthemia Gravis may be handled with short-acting anticholinesterase medication.” (c) “Parkinson’s illness could have catechol O-methyltransferase (COMT) inhibitors prescribed together with levodopoa-carbidopa (Sinemet).” (d) “Purchasers with A number of Sclerosis typically obtain Intravenous immunoglobulin G (IV IgG).” The nurse has attended a employees growth convention on Meniere’s Illness. Which of the next statements, if made by the nurse would require follow-up? 25 (a) “Meniere’s Illness signs end result from extra endolymphatic fl uid within the interior ear.” (b) “Purchasers with Meniere’s Illness are inspired to have a low salt eating regimen.” 26 61. 62. 63. 64. (c) “Assistive listening gadgets are required for shoppers with Meniere’s Illness.” (d) “Stress is suspected to have a task in Meniere’s Illness.” The nurse is admitting a shopper to the emergency division who’s reporting progressive visible impairment and lack of peripheral imaginative and prescient. The nurse ought to acknowledge that these signs are in step with the medical prognosis of (a) macular degeneration (b) closed angle glaucoma (Cc) senile cataract (d) retinal detachment The nurse is caring for a shopper who has left ventricular failure. Which of the next ought to the nurse acknowledge as being in step with this prognosis? (a) 3+ pedal edema (b) jugular vein distention (c) oxygen saturation of 96% (d) wheezing throughout expiration The nurse has attended a employees growth convention on making ready shoppers for neurological diagnostic checks. Which of the next statements, if made by the nurse would require follow-up? (a) “The electromyogram (EMG) is carried out by introducing small needle electrodes into muscle mass.” (b) “After having a Positron Emission Tomography (PET) of the top the shopper can resume regular actions.” (c) “The electroencephalogram (EEG) would require the shopper to be NPO for 12 hours earlier than the take a look at.” (d) “After the lumbar puncture (LP) the shopper might want to lie fl at for about 3 hours.” The nurse has turn out to be conscious of the next shopper conditions. It will be a precedence for the nurse to intervene if a shopper 27 69. The nurse is caring for a 72-year-old shopper who was just lately identified with metastatic breast most cancers. The shopper is expressing emotions of despair and is asking 30 70. 71. 72. 73. the nurse, “Why me?” In response to Erikson, which developmental stage is the shopper experiencing? (a) Trade vs. inferiority (b) Ego integrity vs. despair (c) Generativity vs. stagnation (d) Intimacy vs. isolation The nurse is caring for a number of shoppers who’ve been prescribed diuretics. The nurse ought to educate about growing the consumption of citrus fruits and bananas to the shopper who has been prescribed (a) amiloride (Midamor ) (b) spironolactone (Aldactone) (c) torsemide (Demadex) (d) triamterene (Dyrenium ) The nurse in a well being clinic is reviewing prescribed medicines with a number of shoppers. It will be a precedence for the nurse to observe up with the shopper who states (a) “I’m taking losartan (Cozaar) to decrease my blood stress.” (b) “I crush my verapamil (Calan SR) to make it simpler to swallow.” (c) “I attempt to keep away from sudden place adjustments since I’m taking hydralazine (Apresoline).” (d) “1 won’t use any salt substitutes since I’m taking captopril (Capoten).” The nurse is growing a plan of take care of a shopper identified with fi bromyalgia. Which nursing prognosis ought to the nurse embrace? (a) Sleep sample disturbance (b) Threat for an infection (c) Fluid quantity defi cit (d) Urge urinary incontinence The nurse has attended a employees growth convention on sexually transmitted ailments. Which of the next statements, if made by the nurse would require follow-up? (a) “Through the main stage of syphilis a lesion happens on the web site of an infection referred to as a 31 chancre.” (b) “A shopper with HIV who has a studying of 5 or extra on the mantoux take a look at is taken into account to have a constructive fi nding for pulmonary tuberculosis.” 32 78. 79. 80. 81. The nurse has turn out to be conscious of the next shopper conditions. It will be a precedence for the nurse to follow-up if a shopper who (a) had a complete knee substitute 24 hours in the past is utilizing steady passive movement (CPM) exerciser whereas in a supine place (b) is scheduled for a myelogram in 4 hours and states “I can’t drink any liquids till after the process is fi nished.” (c) had a complete knee substitute 24 hours in the past and is sitting in a fowlers place to eat a meal (d) had a pin inserted 4 hours in the past for a fractured femur has a small quantity of vibrant pink bleeding on the pin web site The nurse is educating a shopper about crutch strolling. Which of the next statements if made by the shopper signifies a necessity for additional educating? (a) “My elbows ought to be fl exed 20 – 30 levels, whereas strolling.” (b) “Once I climb stairs I advance my affected leg fi rst, with my crutches.” (c) “I don’t apply stress below my arm once I use my crutches.” (d) “W hen I’m going to take a seat in a chair I put each crutches within the hand on my unaffected facet.” The nurse on an orthopedic unit has turn out to be conscious of the next shopper conditions. It will be a precedence for the nurse to follow-up if a shopper who (a) had a complete hip substitute 8 hours in the past has had 100 ml of bloody drainage within the closed wound suction machine (b) has an exterior fi xation machine after a restore of a fractured femur is requesting ache remedy (c) had an open discount and inner fi xation (ORIF) of a fractured femur 12 hours in the past has developed a small rash on the chest and neck (d) had a complete hip substitute three hours in the past has a temperature of 37.8° C (100.2° F) The nurse is caring for a shopper with a smooth tissue harm. The shopper stories utilizing a natural treatment for 3 weeks previous to looking for well being care however can’t bear in mind what was taken. The nurse ought to acknowledge that which of the next natural cures 35 may be utilized successfully for smooth tissue accidents? (a) Saint John’s Wort (b) Kava Kava 36 82. 83. 84. 85. (c) Dong—Quai (d) Aloe Vera A shopper with left-sided weak spot following a cerebral vascular accident (CVA) is studying to ambulate with a cane. The nurse ought to educate the shopper to (a) maintain the cane on the left facet and transfer the cane with the precise leg (b) maintain the cane on the precise facet and transfer the cane with the left leg (c) maintain the cane on the left facet and transfer the cane with the left leg (d) maintain the cane on the precise facet and transfer the cane with the precise leg The nurse has turn out to be conscious of the next shopper conditions. It will be a precedence for the nurse to intervene if a shopper (a) scheduled for an EEG is washing the hair (b) is being transported to have a magnetic resonance picture (MRI) take a look at and is hooked up to a pulse oximeter (c) is being taught to carry the breath at intervals throughout a computerized tomography (CT Scan) (d) on protecting precautions is consuming soup introduced in by a customer The nurse is reviewing laboratory knowledge of the next shoppers. It will be a precedence for the nurse to follow-up with the first well being care supplier if a shopper with (a) coronary artery illness has a low density lipoprotein (LDL) stage of 129mg/dl (b) main hypertension has a sodium stage of 144mEq/L (Cc) rhinosinusitis has a white blood rely (WBC) of 11,500/ul (d) diabetes mellitus sort 1 has a glycosylated hemoglobin (HbA 1c) stage of 12% The nurse engaged on a maternity unit has turn out to be conscious of the next shopper conditions. It will be a precedence for the nurse to intervene if a shopper states (a) “I cannot take my terbutaline (Brethine) if my pulse is bigger than 110 beats per minute.” (b) “It’s regular for my 10 hour previous child to have blue ft and palms.” (c) “I can not breast feed as a result of my nipples are cracked and sore.” (d) “I’ve modified my perineal pad each two hours since I delivered my child 12 37 (d) ask the dad or mum to elucidate the accidents 40 91. The nurse within the emergency division is admitting a shopper who’s hallucinating and stories bugs crawling on the pores and skin. The shopper’s pulse fee is 124 and the respiratory fee is 10. The nurse notes muscle twitching of the decrease extremities. It will be a precedence for the nurse to find out if the shopper has (a) a historical past of consideration defi cit dysfunction (b) just lately ingested cocaine (c) taken disulfi ram (Antabuse) throughout the previous 24 hours (d) an allergy to anticholinergics 92. The nurse is growing a nursing care plan for a shopper who’s within the manic part of bipolar dysfunction. Which intervention ought to the nurse embrace within the plan of care? (a) Present the shopper with fi nger meals (b) Interact the shopper in aggressive video games (c) Encourage the shopper to keep away from meals that comprise tyramine (d) Place the shopper on direct suicide commentary 93. The first well being care supplier has prescribed amitriptyline (Elavil) 150 mg P.O. every day for a shopper identified with main despair. Select all the right solutions for nursing issues for the administration of Elavil. (a) administer this remedy with meals (b) educate the shopper that the urge for food shall be diminished (c) administer this remedy within the morning (d) monitor the shopper for hypertension (e) Instruct the shopper that this remedy could trigger the event of a dry mouth (f) inform the shopper that this remedy could trigger photosensitivity 94. A forty five yr previous shopper who was just lately identified with terminal most cancers says to the nurse “Tf God might solely let me reside lengthy sufficient to place my daughter by way of school, I wouldn’t thoughts coping with this sickness.” The nurse caring for this shopper acknowledges this assertion as refl ective of which stage of grieving? (a) Denial (b) Acceptance 41 (c) Bargaining (d) Anger 42 101. (c) the medicines may be discontinued in a single month (d) the shopper would require hepatic operate checks each month The nurse is reviewing a shopper’s arterial blood fuel (ABG) outcomes which reveal the next: pH: 7.35; PaO»: 75 mm Hg; PaCO: 55 mm Hg; HCOs: 30 mEd/L. The nurse ought to acknowledge that this result’s suggestive of which acid base imbalance? (a) compensated metabolic acidosis (b) compensated respiratory acidosis (c) compensated metabolic alkalosis (d) compensated respiratory alkalosis The nurse ina properly youngster clinic is taking the very important indicators of a 4 yr previous shopper. The nurse obtains the next readings: temperature 98.2°F, pulse 110, respirations 22, blood stress 86/60. The nurse ought to (a) ask if the dad or mum is aware of what the kid’s pulse fee is often (b) encourage the kid to relaxation for 10 minutes and reassess very important indicators (c) doc the fi ndings within the shopper’s medical document (d) notify the first well being care supplier of the fi ndings 102. A nurse has turn out to be conscious of the next shopper conditions. Which of the next if noticed reveals that the UAP wants additional educating? The UAP (a) avoids washing the physique of a Jewish shopper till thirty minutes after dying (b) permits the household of a Buddhist shopper to chant ritual rites on the bedside of their deceased father (c) gives espresso and cookies for the visiting household of a Mormon shopper (d) removes a cup of tea from the breakfast tray of a Seventh Day Adventist shopper 103. A nurse has turn out to be conscious of the next conditions. Which ought to trigger the best concern for the nurse? A shopper with (a) a bipolar dysfunction who’s screaming on the nurses station (b) congestive coronary heart failure has bi-pedal edema (c) a transurethral resection of the prostate (TURP) has blood tinged urine within the urinary bag 45 (d) radon seed implants is seen ambulating in corridor 46 104. The nurse is caring for shoppers who have been just lately faraway from a falling constructing. Who would the nurse see fi rst? The shopper with (a) fi rst diploma burns and a sprained left ankle (b) dilated pupils and a small laceration to the left ear (c) a fracture of the precise tibia and belly ache (d) confusion and smooth tissue accidents 105. A nurse is making ready assignments for the day. Which of the next shoppers ought to the nurse see fi rst? A (a) 48 y.o ventilator dependent shopper who wants a sputum specimen (b) 54 y.o on Bleomycin (Blenoxane) complaining of vomiting (Cc) 65 y.o with pneumonia who wants to begin IV antibiotics (d) 72 y.o asthmatic complaining of SOB after utilizing Albuterol (Ventolin) 106. A nurse engaged on a pediatric unit is made conscious of the next conditions. Which youngster is the precedence to be seen fi rst? A (a) 1 yr previous with Tetralogy of Fallot with bluish discoloration to the lips whereas crying (b) 2 yr previous with renal failure with a potassium stage of 6.4 mEq/L (Cc) 3 yr previous identified with Rheumatic Coronary heart Fever with an elevated ESR fee (d) 4 yr previous identified with Rota-Virus having 5 bowel actions throughout an 8 hour shift 107. After receiving report from the night time nurse, which of the next sufferers ought to 108. the nurse see fi rst? (a) A 30- yr previous girl who’s 38 weeks pregnant complaining of a small quantity of vaginal bleeding (b) A 42- yr previous man with left sided weak spot asking for help to the commode (c) A 55-year previous girl complaining of chills who’s scheduled for a complete belly hysterectomy (d) A 77-year previous man with a nasogastric tube who had a gastrectomy yesterday Which of the next shoppers is acceptable to assign to an LPN for remedy administration? * 47 (€) Doc hourly urine output (f) Measure weight 50 113. A psychological well being nurse is fl oated to work on the medical surgical unit. Which shopper could be most applicable to assign to the psychological well being nurse? A shopper that: (a) is 4 hours put up operative following cholecystectomy (b) has dehydration and desires IV fl uids (c) has mechanical air flow and must be suctioned (d) is in traction for a damaged femur 114. A nurse is caring for the next shoppers. Which shopper is the precedence to be assigned to a non-public room? A shopper with (a) HIV (b) Cirrhosis of the liver (Cc) Scabies (d) Pneumonia 115. A nurse is caring for the next shoppers. Which shopper is a precedence to be assigned to a non-public room? A shopper with (a) Rubeola (b) Rubella (c) Klebsiella Pneumoniae (d) Pediculosis 116. The nurse is caring for a number of shoppers requiring isolation. There may be one non-public room accessible on the unit. The nurse ought to place the very best precedence on assigning which of the next shoppers to the non-public room? The shopper (a) with fever and diarrhea for two days after taking antibiotics (b) who’s HIV * with a temperature of 101° (Cc) with low grade fever and night time sweats (d) with Leukemia whose temperature is 100° 117. The an infection management nurse is making rounds on a Medical Surgical unit. Which of the next, if noticed by the nurse requires instant intervention? (a) A UAP is noticed sporting gloves whereas emptying a urine drainage bag (b) An RN is noticed sporting a surgical face masks whereas caring for a shopper 51 with tuberculosis (TB) in a damaging stress room (c) An LPN is noticed sporting a robe and gloves whereas caring for a mentally ailing shopper with Clostridium Diffi cile toxin 52 (b) 1 week (c) 2 – 3 weeks (d) 2 – 4 months 123. A shopper is admitted to Labor and Supply at 38 weeks gestation. The nurse could be right to state that the shopper is within the second stage of labor when (a) the placenta is delivered (b) bulging is seen within the perineum (Cc) contractions are irregular (d) rubra lochia is famous 124. A shopper on an inpatient psychiatric unit believes the employees is making an attempt to poison her. The nurse ought to: (a) Clarify that the employees is trust-worthy (b) Enable the shopper see others eat their meals (Cc) Supply factory-sealed meals and drinks (d) Style the meals in entrance of the shopper to show it’s edible 125. A nurse is caring for a shopper taking Thorazine (Chlorpromazine). Which assertion reveals an understanding of directions concerning this remedy? The shopper states (a) “I’ll take my drugs each time I hear voices” (b) “I’ll drink additional fl uid to forestall this dry mouth “ (c) “I’ll put on a large brim hat up on the seaside” (d) “I’ll cease my remedy once I really feel higher” 126. An emergency room nurse is caring for a shopper with suspected phenobarbitol use. Which of the next will end result if the shopper has a barbituate dependancy? (a) Watery eyes, sluggish shallow respiration, frequent sniffi ng (b) Dilated pupils, shallow respirations, weak and speedy pulse (c) Constricted pupils, respirations depressed, nausea, vomiting (d) Sluggish pupils, elevated respirations, decreased pulse 55 127. The nurse has attended a employees growth convention on cultural issues for shopper’s receiving hospice care. Which of the next statements if made by the nurse would require observe up? 56 (a) The household of a shopper of Buddhist religion could ask for a priest to be current on the time of dying (b) The household of a shopper of Jewish religion could request to have mirrors lined after the dying of the shopper (Cc) The household of a shopper of Muslim religion could request that the physique of the shopper be turned to face the south east on the time of the shopper’s dying (d) The household of a shopper of Hindu religion could request that the physique be bathed after their dying 128. A nurse is caring for a shopper admitted with Laénnec’s cirrhosis. Which vitamin complement could also be obligatory to incorporate? (a) Vitamin B6 (b) Vitamin A (c) Vitamin B1 (d) Vitamin C 129. A nurse is caring for a shopper with Celiac illness. Which of the next statements reveals that educating has been efficient? (a) “I take pleasure in consuming oatmeal for breakfast.” (b) “1 dislike rice so will probably be straightforward to keep away from.” (c) “I’ll have popcorn and juice whereas I’m on the motion pictures.” (d) “I can have eggs with my rye toast.” 130. The nurse is observing a shopper with renal failure choose meals from the lunch menu. Which of the next choices if made by the shopper would point out a necessity for additional educating? (a) Haddock and spaghetti (b) Cereal with buttermilk (c) Corned beef and rice (d) Orange juice with wheat toast 131. The nurse is aware of that the plan of take care of a shopper with extreme Ulcerative Colitis would come with which of the next? (a) Low protein, excessive carbohydrate eating regimen (b) Low residue, excessive protein (c) Excessive protein, excessive residue 57 60 138. A doctor has chosen a drugs for a shopper with glaucoma that’s to be administered one time per week. Which of the next medicines is a direct performing parasympathomimetic agent used as a miotic within the therapy of glaucoma? (a) humorsol (demecarium) (b) cyclogyl (cyclopentolate) (c) pilocarpine (pilocar) (d) timolol (timoptic) 139. The nurse is caring for a shopper taking the remedy Clozaril (Clozapine). Which of the next statements if made by the shopper reveals that educating has been efficient? (a) “I’ll improve my glucose consumption.” (b) “I ought to embrace bulk and fl uids in my eating regimen.” (c) “I ought to count on a lower in my threat of an infection.” (d) “I have to do not forget that hypertension is widespread.” 140. A scholar nurse is making ready to manage Cardura (Doxazosin). Which of the next ought to be included in educating? Choose all that apply. (a) keep away from driving (b) count on elevated libido (c) double doses if one dose is missed (d) proceed to take chilly cures (e) blurred imaginative and prescient could happen 141. The dad or mum of a kid taking Concerta (Methylphenidate) calls the clinic and stories the next signs. The nurse is aware of which of the next is an anticipated facet impact? (a) lethargy (b) elevated urge for food (c) weight acquire (d) metallic style within the mouth 142. The nurse is caring for a 76 yr previous shopper whose previous medical historical past contains 61 coronary artery illness. A evaluate of the laboratory outcomes reveal: HDL 34, LDL 168 and whole Ldl cholesterol 270. Which of the next medicines is likely to be included within the plan of care? (a) Tagamet (Cimetidine) 300 mg po 4 instances a day (b) Coumadin (Warfarin Sodium) 2 mg po at bedtime 62 147. The nurse is caring for a shopper with hypothyroidism. Anticipated fi ndings for this dysfunction embrace: Choose all that apply. (a) Constipation (b) Dry pores and skin (c) Anorexia (d) Insomnia (@) Bradycardia (f) Palpitations 148. Whereas doing a routine examine up with the gynecologist, a 32 yr previous shopper complains of frequent yeast infections. The nurse is aware of which of the next could also be famous? (a) a fasting glucose of 132 mg/dl (b) a white blood rely of 10,000 cc mm (c) a HGB (hemoglobin) of 15 mg/dl (d) a BUN (blood urea nitrogen) of 19 mg/dl 149. A nurse is offering take care of a shopper with Kind I IDDM complaining of a headache. What ought to the nurse do fi rst? (A) Give one cup of orange juice (b) Name the nurse in cost (c) Examine the shoppers glucose stage (d) Administer insulin as prescribed 150. The cost nurse was alerted concerning the want for a number of admissions following a twister. Which of the next shopper’s could be applicable for the cost nurse to advocate for discharge? * (a) A dient with a T3 harm reporting headache (b) A shopper with a chest tube that has steady effervescent within the water seal chamber (C) The bipolar shopper with a Lithium stage of 1.8 mEq/L (d) The COPD shopper with an ABG studying of pH 7.34 PaO2 89 PaCO2 55 HCO3 23 65 Bonus Questions ( Sizzling Spot 1. The nurse is assessing a shopper’s pulses after a cardiac catheterization utilizing the femoral artery. Along with the posterior tibial pulse place an X on the opposite pulse web site that ought to be assessed. 2. A toddler presents to the clinic with fever, lethargy, nausea, and vomiting, and erythema. Erythema Infectiosum (Fifth Illness) is suspected. Place an X the place the nurse would count on the preliminary rash to seem. 3. The nurse is making ready to manage an intramuscular injection to an toddler. Determine the realm that the injection ought to be administered. 36 6. A nurse is making ready to manage an injection. Determine the realm often known as the dorsogluteal web site for intramuscular injections. 39 Use an X to determine the realm of the lungs the place the chest X-ray is more likely to reveal infi ltrates in a shopper identified with tuberculosis (TB). 40 Rationales 1, A. The traditional potassium stage is 3.5 — 5.0 mEq/L. Giving Kayexalate on this state of affairs could trigger the shopper to lose potassium, inflicting hypokalemia, due to this fact the drug just isn’t indicated; the therapeutic stage for Dilantin is 10 — 20 mcg/ml, a stage of 8 is sub therapeutic thereby growing the danger of seizure exercise. Acetaminophen may be safely prescribed to shoppers with ASA sensitivity. Azithromycin (Zithromax) may be safely prescribed for shoppers with sensitivity to Penicillin. Protected Efficient Care Atmosphere; Administration of Care 2. A. Knowledgeable consent, clarification and choice making should happen earlier than sedation is given; therapeutic interventions for retinal detachment embrace bedrest with the realm of detachment in a dependent place to advertise therapeutic; the solid ought to be dealt with with the palms of the palms whereas moist to forestall denting; a broad 41 battery; C is an instance of negligence not malpractice and D is an instance of battery not assault. Protected Efficient Care Atmosphere; Administration of Care 11. — C. Vomiting and diarrhea may be managed on a non-emergent foundation; shoppers reporting “indigestion” could also be experiencing a cardiac occasion; medical manifestations suggestive of belly aortic aneurysm embrace belly mass and belly throbbing; the shopper who’s 6 weeks pregnant experiencing belly ache have to be evaluated to rule out ectopic being pregnant which could possibly be life threatening. Protected Efficient Care surroundings; Administration of Care 12. __D. Following cardiac catheterization utilizing the femoral artery, the shopper stays on bedrest for two to six hours with the affected leg straight and the top of the mattress elevated to 30 levels; blood tinged sputum is an anticipated fi nding after bronchoscopy; elimination of fl uid from the peritoneal cavity as in paracentesis will end in decreased belly girth; put up lumbar puncture headache starting from delicate to extreme could seem a couple of hours to days following the process. Protected Efficient Care Atmosphere; Administration of Care 45 13. __D. Purchasers with a historical past of advanced partial seizures could black out for one to a few minutes. They expertise automatisms (the shopper just isn’t conscious of the habits) comparable to lip smacking, patting, and choosing of the garments. This shopper ought to be seen fi rst; dribbling, urinary frequency and burning on urination could also be anticipated after an indwelling catheter is eliminated; fl exion and extension of the neck is contraindicated with cervical traction; returning the confused shopper with Alzheimer’s illness to their room just isn’t a precedence. Protected Efficient Care Atmosphere; Administration of Care 14. _B. Oatmeal is contraindicated for kids with Celiac illness. These shoppers ought to be on a gluten free eating regimen. Meals to be prevented embrace barley, rye, oats and wheat; the opposite decisions are permissible as part of the dietary plan. Protected Efficient Care Atmosphere; Administration of Care 15. C.A sterile glove, not clear, ought to be used on the dominant hand throughout tracheal suctioning to forestall an infection; the apical pulse ought to be assessed for one full minute previous to the administration of Digoxin (Lanoxin); elevation of the stump following amputation is carried out for the fi rst 24 hours solely to forestall hip or knee fl exion contracture; shoppers ought to be positioned on the operative facet to advertise lung growth of the unaffected lung. Protected Efficient Care Atmosphere; Administration of Care 16. A. The new child ought to be positioned in a rear going through automobile seat with applicable restraints till about one yr of age and no less than 20 kilos; the lap portion of the shoulder belt ought to be positioned cosy across the hips, by no means the stomach; all youngsters below the age of 12 ought to be positioned within the rear seat of the car. Protected Efficient Care Atmosphere; Security and An infection Management 17. A. Vancomycin resistant enterococcus (VRE) is unfold by direct contact; illness which are transmitted by droplets (sneezing, coughing) embrace infl uenza, pneumonia, streptococcal pharyngitis; protecting isolation precautions are used for individuals with suppression of the immune system; airborne precautions are instituted for ailments transmitted through the air comparable to measles (rubeola), tuberculosis (TB), and varicella (chickenpox). Protected Efficient Care Atmosphere; Security and An infection Management 18. _D. Use of a robe to forestall contact with the shopper or shopper contaminated objects is desired; a particulate respirator masks and damaging stress room is used through the care of somebody with tuberculosis; prohibition of fl owers and reside crops is critical for the shopper on protecting precautions to forestall an infection. Protected Efficient Care Atmosphere; Security and An infection Management 19. D.A white blood cell rely of two,500/mm:? is low due to this fact the shopper is in danger for an infection. Protecting precautions ought to be carried out. The traditional White blood cell 46 not launched till after one yr of age. Physiological Integrity; Primary Care and Consolation 26. C. The kid with thrombocytopenia must be protected against harm secondary to the danger of bleeding. Use of a board sport, a quiet exercise gives diversion and challenges that’s developmentally applicable whereas eliminating the danger of harm; fi nger paints is relevant to a preschool shopper; the ball and bat is prevented to forestall harm; the stuffed toy could also be provided to the toddler. Well being Promotion and Upkeep 27. A.The kid experiencing fever and hypotension ought to be seen fi rst, they’re on the highest threat on this state of affairs for decompensation; the common blood stress for a toddler is 92/56; the kid with bronchial asthma just isn’t acutely ailing right now; ache is anticipated with a bone fracture, administration of ache is essential however doesn’t take precedence; ulcerative colitis is anticipated to supply 10 — 20 bloody stools per day, this isn’t the precedence on this state of affairs. Protected Efficient Care surroundings; Administration of Care 28. _B.The dad or mum ought to be taught the ESSR (Enlarged nipple, Stimulate Suck by rubbing the nipple on the decrease lip, Relaxation after every swallow to permit toddler to finish swallowing) technique of feeding to lower the danger of aspiration; the toddler ought to be fed in an upright place; susceptible place and pacifi ers shouldn’t be used. Physiological Integrity; Physiological Adaptation 29. C. In response to Sigmund Freud, the phallic stage happens between 3 — 6 years of age. Throughout this stage the kid experiences unconscious sexual attraction to the dad or mum of the other intercourse. That is referred to as the Oedipal Complicated. The assertion is refl ective of this stage of growth. The opposite decisions should not right actions. Protected Efficient Care surroundings; Administration of Care 30. D. Coarctation of the aorta is characterised by narrowing of the aorta. On account of this narrowing, absent femoral pulses, poor weight acquire and elevated blood stress within the higher extremities are anticipated fi ndings. A excessive pitched murmur just isn’t current. Physiological Integrity; Physiological Adaptation 31. B,C, and F. Youngsters experiencing acyanotic defects could expertise tachycardia, tachypnea and delay in progress and growth; poor suck refl ex, bradycardia, and fainting spells are indicative of cyanotic defects. Physiological Integrity; Physiological Adaptation 32. C. Security knowledge from a number of research present that acellular pertussis vaccine trigger fewer 49 opposed reactions than whole-cell vaccines. Pre-term infants usually don’t wait 6 months earlier than starting vaccinations; the fi rst Hepatitis B vaccine is given at beginning; the 50 Haemophilus infl uenzae sort b (HIB) is given at 2 months, 4 months, and 6 months and between 12—15 months. Well being Promotion and Upkeep 33. _D. Pyloric Stenosis is hypertrophy of the muscle mass of the pylorus inflicting narrowing of the pyloric canal between the abdomen and duodenum. A attribute olive formed mass could also be palpated within the epigastrium to the precise of the umbilicus. Intussusception is characterised by currant jelly stools. Hirschprung’s illness (congenital mega colon) leads to ribbonlike foul smelling stools; a toddler with an umbilical hernia has swelling or protrusion across the umbilicus that’s reducible. Physiological Integrity; Physiological Adaptation 34. _B. By the age of three, a toddler ought to be capable to trip a tricycle independently; the pre- faculty youngster just isn’t in a position to discriminate between fantasy and actuality. That is the developmental activity of a college age youngster; at 3 years of age the vocabulary is at about 900 phrases; cooperative play with the incorporation of imaginary buddies is widespread on this age group. Well being Promotion and Upkeep 35. C,D, and E. All of those duties are throughout the job description of a Certifi ed Nursing Assistant and may be safely delegated; A, B, and F would require evaluation, nursing intervention and affected person schooling which is the function of the nurse. Protected Efficient Care surroundings; Administration of Care 36. C. Purchasers being handled with Zidovudine (AZT) ought to have routine monitoring of CBC (full blood rely), hepatic and renal operate research. Physiological Integrity; Physiological Adaptation 37. D,C,A, and B. Inspection is finished fi rst. Auscultation is carried out earlier than percussion and palpation to lower the danger of stimulating the bowel which might end in false constructive fi ndings. Well being Promotion and Upkeep 38. B.The presence of calf ache postoperatively is suggestive of the event of DVT (deep vein thrombosis) which is a doubtlessly life threatening put up operative complication of shoppers present process gynecologic surgical procedures. This shopper ought to be seen fi rst; the opposite conditions should not the precedence on this state of affairs. Protected Efficient Care surroundings; Administration of Care 39, 21 gtts/min. Quantity 1000ml X Drip issue (10gtts/ml) Time in minutes (8hours x 60 minutes) Physiological Integrity; Pharmacological and Parenteral Therapies 40. 30 ml. Desired quantity (20mEq) X Amount (15ml) Quantity 51 shoppers experiencing Dumping Syndrome. The shopper ought to be taught to keep away from consuming with meals. Protected Efficient Care Atmosphere; Security and An infection Management 54 49. __B. Assessing whether or not or not the kid took these medicines previously will assist to find out if an allergic response occurred; the really helpful pediatric dose for ampicillin (Omnipen) is 50mg/kg/day; mixing the remedy with apple sauce will assist to make it palatable to the kid; it’s not obligatory to attend for throat tradition end result, nevertheless the nurse ought to get hold of the tradition earlier than giving the fi rst dose of antibiotic. Physiological Integrity; Pharmacological and Parenteral Therapies 50. __B. It can be crucial that the kid with sickle cell anemia keep away from different youngsters with infections as a result of an infection might precipitate a sickle cell disaster; chilly water is contraindicated to forestall vasoconstriction; aspirin is prevented in giant doses as a result of threat of metabolic acidosis; contact sports activities ought to be prevented. Physiological Integrity; Discount of Threat Potential 51. A. At5 months previous the usually growing toddler ought to be capable to roll from stomach to again; sitting with out assist in addition to hand dominance is anticipated at 7-9 months; imitative speech ought to develop between 10-12 months of age. Well being Promotion and Upkeep 52. B. Gifting away one’s belongings could possibly be a sign that this shopper is suicidal and has made a plan to finish their life; this shopper is the precedence to make sure security. One- to- one commentary could also be wanted. Protected Efficient Care surroundings; Administration of Care 53. B. Antacids shouldn’t be administered on the similar time with iron preparations as a result of absorption is inhibited; to reinforce the antacid impact Maalox (aluminum hydroxide/magnesium hydroxide) is run 1-3 hours after meals and at bedtime; shaking the remedy and assessing for the presence of gastric ache is relevant. Physiological Integrity; Pharmacological and Parenteral Therapies 54. _D. Vitamin B6 just isn’t used within the administration of macular degeneration; shoppers who’ve had gastrectomy could require Vitamin B 12 complement secondary to the absence of intrinsic issue; Vitamin D is critical for the correct absorption of calcium; yellow greens comparable to squash, pumpkin, and carrots are good sources of Vitamin A. Physiological Integrity; Primary Care and Consolation 55. A. Statements made by the mom of the toddler sleeping for extended durations assist the prognosis. Observe up is required for diagnostic workup to confi rm this 55 dysfunction. Indicators of congenital hypothyroidism embrace lethargy, poor feeding, constipation and bradycardia; excessive pitched cry just isn’t suggestive of hypothyroidism; frequent free 56 63. C.NPO just isn’t required previous to an EEG. The shopper is allowed to have breakfast if prescribed. Caffeine and different stimulants ought to be prevented for twenty-four hours previous to the process; the opposite statements are true of these diagnostic checks, due to this fact observe up just isn’t required. Physiological Integrity; Discount of Threat Potential 64. _B. Transphenoidal hypophysectomy is the surgical elimination of the pituitary gland by way of the sphenoid sinus. Affected person educating contains avoidance of any exercise that raises intracranial stress; bedrest is indicated following radium implants; meals excessive in sodium are inspired for shoppers on Lithium (Eskalith) remedy to forestall hyponatremia which predisposes the shopper to Lithium toxicity; postoperative positioning following a repaired retinal detachment is on the operative facet. Protected Efficient Care Atmosphere; Security and An infection Management 65. A. Meals containing oxalate ought to be restricted to forestall recurrent renal stones. Examples of those meals are spinach, rhubarb, strawberries, tea, peanuts and wheat bran. Physiological Integrity; Primary Care and Consolation 66. _D. Hyperkalemia can lead to critical opposed results to excitable tissues particularly the center, inflicting altered cardiac operate; the BUN and creatinine are elevated previous to dialysis on account of elevated circulating wastes within the blood stream; a sodium stage of 145 mEq/L is throughout the regular vary of 135-145 mEq/L. Physiological Integrity; Discount of Threat Potential 67. A. Feminine shoppers with new onset diabetes mellitus could report latest main or minor infections significantly vaginal yeast infections; elevations in white blood cell rely, hemoglobin and blood urea nitrogen should not the precedence on this state of affairs. Physiological Integrity; Discount of Threat Potential 68. A. Testicular most cancers is commonest in males 15-35 years of age. Well being Promotion and Maintenence 69. _B. Erikson states that the grownup over the age of 65 goes by way of the developmental stage of ego integrity vs. despair. This shopper is experiencing despair secondary to the prognosis of breast most cancers; the college age youngster experiences trade vs. inferiority; generativity vs. stagnation is current within the center aged grownup; intimacy vs. isolation is related to the younger grownup. Well being Promotion and Maintenence 70. C. Demadex (torsemide) is a potassium depleting diuretic; shopper schooling ought to be carried out to incorporate meals excessive in potassium to forestall hypokalemia; Midamor (amiloride), 59 Aldactone (spironolactone) and Dyrenium (triamterene) are all potassium sparing diuretics; the nurse would restrict meals containing potassium with use of those medicines. Physiological Integrity; Pharmacological and Parenteral Therapies 60 71. __B. Calan SR is a sustained launch remedy, it ought to by no means be crushed, chewed or damaged; Cozaar (Losartan) is prescribed to manage hypertension. Purchasers taking antihypertensives ought to keep away from sudden place adjustments to forestall orthostatic hypotension; shoppers taking Captopril (Capoten) have to keep away from the usage of salt substitutes secondary to the danger of hyperkalemia. Physiological Integrity; Pharmacological and Parenteral Therapies 72. A. Sleep disturbances is attribute of fi bromyalgia associated to extreme exhaustion. Different manifestations are ache, muscle stiffness and spasms with sensory adjustments; threat of an infection, fl uid quantity defi cit and urge incontinence just isn’t related to fi bromyalgia. Physiological Integrity; Physiological Adaptation 73. D.HPV (human papilloma virus), not Chlamydia is the sexually transmitted an infection linked with cervical most cancers; the opposite statements are correct, they don’t want observe up. Physiological Integrity; Physiological Adaptation 74. A. The N95 particulate respirator masks is required by the nurse coming into the room of the shopper being handled for TB. A surgical masks doesn’t defend towards transmission, nevertheless throughout transport out of the room the surgical masks ought to be positioned on the shopper; varicella zoster requires droplet precautions which embrace closing the door; RSV (respiratory synctival virus) is unfold by direct contact with a contaminated shopper or contaminated object. Provides are left within the shopper’s room for his or her use solely; Ebola virus is current in all physique fl uids, sporting a robe, masks and gloves are obligatory to forestall publicity and unfold. Protected Efficient Care Atmosphere; Security and An infection Management 75. _B.This shopper’s care requires involvement of assorted members of the well being care group (multidisciplinary) i.e. nursing, medication, OB/GYN, social employee, nutritionist; the opposite shoppers don’t want as many well being care staff for the supply of care. Protected Efficient Care Environmen ; Administration of Care 76. B.The traditional fetal coronary heart fee (FHR) is 120-160 beats per minute, nevertheless the shopper who has a constant FHR of 132 beats per minute ought to be seen fi rst to evaluate for fetal misery. There ought to be a fl uctuation of the center fee 6-25 beats per minute which signifies a properly oxygenated and functioning central nervous system; the opposite decisions should not the precedence on this state of affairs. Protected Efficient Care Atmosphere; Administration of Care 61 85. C. Cracked nipples should not a contraindication to breast feeding. The mom ought to be instructed to reveal the nipples to air for 10-20 minutes after feeding, rotate the 64 place of the child for every feeding and be sure that the child is latched on to the areola not simply the nipple. Protected Efficient Care Atmosphere; Administration of Care 86. __B,A, D, C. The American Coronary heart Affiliation recommends this sequence of CPR for an grownup to supply rescue assist and keep some oxygen and blood fl ow to the center and mind. Physiological Integrity; Physiological Adaptation 87. —C. The shopper with Tuberculosis (TB) is positioned on airborne precautions which embrace placement in a damaging stress room with the door closed and use of a particulate respirator masks; a robe and gloves should not wanted when speaking with the shopper or taking the blood stress; droplet precautions are used for meningitis, HIB (haemophilus infl uenzae sort b), mumps, rubella, pertussis and epiglottitis. Physiological Integrity; Physiological Adaptation 88. _D. The precedence on this state of affairs is shopper security. The nurse ought to be relieved of their assigned shoppers since these behaviors recommend that the nurse could also be impaired; the cost nurse shouldn’t confront the opposite nurse. As a substitute, a transparent factual description of the state of affairs ought to be documented then reported to the nursing supervisor. Protected Efficient Care Atmosphere; Security and An infection Management 89, _B. When responding to a fi re, there are 4 sequential priorities that have to be adopted: Rescue the shoppers, which was carried out on this state of affairs, Alarm (name for added assist), Confi ne the fi re, Extinguish the fi re. Protected Efficient Care Atmosphere; Security and An infection Management 90. C. Reporting of suspected youngster abuse and maltreatment is remitted by most states. The aim is to guard the kid from additional abuse. Documentation ought to be clear and goal—the document could also be subpoenaed in court docket. Protected Efficient Care Atmosphere; Security and An infection Management 91. B. Cocaine use is commonly related to the presence of hallucinations, tachycardia and respiratory despair. Untreated, this shopper is more likely to die, they’re the precedence on this state of affairs; consideration defi cit dysfunction, use of Antabuse (disulfi ram) or anticholinergic medication don’t produce hallucinations. Protected Efficient Care Atmosphere; Security and An infection Management 92. A.A shopper within the manic part of bipolar dysfunction could have diffi culty assembly dietary wants due to their lack of ability to take a seat nonetheless; aggressive video games are prevented as a result of the shopper is hyperactive, impulsive and distractible. Structured exercise is extra applicable; meals containing tyramine are prevented in shoppers prescribed MAO 65 inhibitors; inserting the shopper on suicide commentary could also be indicated through the depressed part. Psychosocial Integrity 66