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ATI RN HESI Med Surg Custom Exam Questions and Rated A+ Answers, Exams of Advanced Education

Virginia Union University (VUU)Advanced Education

ATI RN HESI Med Surg Custom Exam Questions and Rated A+ Answers

Typology: Exams

2024/2025

Available from 06/05/2025

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ATI RN HESI Med Surg Custom Exam Questions and
Rated A+ Answers
TEST 1
Multiple Choice
Identify the letter of the choice that best completes the statement or answers the question.
1. While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth
on the client's legs. What additional assessment provides further data to support this finding?
a.
Palpate for the presence of femoral pulses bilaterally.
b.
Assess for the presence of a positive Homan's sign.
c.
Observe the appearance of the skin on the client's legs.
d.
Watch the client's posture and balance during ambulation.
2. The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds.
The drug is diluted in 25 ml of D5W to run over 8 hours. How much Streptomycin will the
infant receive?
a.
9 mg.
b.
18 mg.
c.
27 mg.
d.
36 mg.
3. In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse
determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/minute;
urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/dl. Based on these findings,
what intervention should the nurse implement?
a.
Continue the magnesium sulfate infusion as prescribed.
b.
Decrease the magnesium sulfate infusion by one-half.
c.
Stop the magnesium sulfate infusion immediately.
d.
Administer calcium gluconate immediately.
4. A client is on a mechanical ventilator. Which client response indicates that the neuromuscular
blocker tubocurarine chloride (Tubarine) is effective?
a.
The client’s expremities are paralyzed.
b.
The peripheral nerve stimulator causes twitching.
c.
The client clinches fist upon command.
d.
The client’s Glagow Coma Scale score is 14.
5. An elderly female client comes to the clinic for a regular check-up. The client tells the nurse
that she has increased her daily doses of acetaminophen (Tylenol) for the past month to
control joint pain. Based on this client's comment, what previous lab values should the nurse
compare with today's lab report?
a.
Look at last quarter's hemoglobin and hematocrit, expecting an increase today due
to dehydration.
b.
Look for an increase in today's LDH compared to the previous one to assess for
possible liver damage.
c.
Expect to find an increase in today's APTT as compared to last quarter's due to
bleeding.
d.
Determine if there is a decrease in serum potassium due to renal compromise.
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Download ATI RN HESI Med Surg Custom Exam Questions and Rated A+ Answers and more Exams Advanced Education in PDF only on Docsity!

ATI RN HESI Med Surg Custom Exam Questions and

Rated A+ Answers

TEST 1

Multiple Choice Identify the letter of the choice that best completes the statement or answers the question.

  1. While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. What additional assessment provides further data to support this finding? a. Palpate for the presence of femoral pulses bilaterally. b. Assess for the presence of a positive Homan's sign. c. Observe the appearance of the skin on the client's legs. d. Watch the client's posture and balance during ambulation.
  2. The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds. The drug is diluted in 25 ml of D 5 W to run over 8 hours. How much Streptomycin will the infant receive? a. 9 mg. b. 18 mg. c. 27 mg. d. 36 mg.
  3. In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/minute; urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/dl. Based on these findings, what intervention should the nurse implement? a. Continue the magnesium sulfate infusion as prescribed. b. Decrease the magnesium sulfate infusion by one-half. c. Stop the magnesium sulfate infusion immediately. d. Administer calcium gluconate immediately.
  4. A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective? a. The client’s expremities are paralyzed. b. The peripheral nerve stimulator causes twitching. c. The client clinches fist upon command. d. The client’s Glagow Coma Scale score is 14.
  5. An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client's comment, what previous lab values should the nurse compare with today's lab report? a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today due to dehydration. b. Look for an increase in today's LDH compared to the previous one to assess for possible liver damage. c. Expect to find an increase in today's APTT as compared to last quarter's due to bleeding. d. Determine if there is a decrease in serum potassium due to renal compromise.
  1. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement? a. Instruct the parents to hold the aspirin until the child has first had a tepid sponge bath. b. Administer the aspirin with at least two ounces of water or juice. c. Notify the healthcare provider if the child complains of ringing in the ears. d. Advise the parents to question the child about seeing yellow halos around objects.
  2. Which signs or symptoms are characteristic of an adult client diagnosed with Cushing's syndrome? a. Husky voice and complaints of hoarseness. b. Warm, soft, moist, salmon-colored skin. c. Visible swelling of the neck, with no pain. d. Central-type obesity, with thin extremities.
  3. A charge nurse agrees to cover another nurse’s assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? The client a. admitted yesterday with diabetec ketoacidosis whose blood glucose level is now 195 mg/dl. b. with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch. c. post-triple coronary bypass four days ago who has serosanguinous drainage in the chest tube. d. with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.
  4. An outcome for treatment of peripheral vascular disease is, "The client will have decreased venous congestion." What client behavior would indicate to the nurse that this outcome has been met? a. Avoids prolonged sitting or standing. b. Avoids trauma and irritation to skin. c. Wears protective shoes. d. Quits smoking.
  5. The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure? a. Pedal pulses. b. Breath sounds. c. Gag reflex. d. Vital signs.
  1. An 85-year-old male resident of an extended care facility reaches for the hand of the unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation? a. This is sexual harassment and needs to be reported to the administration immediately. b. The UAP needs to be reassigned to another group of residents, preferably females only. c. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need. d. The resident needs to know the rules concerning unwanted touching of the staff and the consequences.
  2. The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. What information should the nurse provide? a. Repair should be done by one month to prevent bladder infections. b. Repairs typically should be done before the child is potty-trained. c. Delaying the repair until school age reduces castration fears. d. To form a proper urethra repair, it should be done after sexual maturity.
  3. In evaluating teaching of a client about wearing a Holter monitor, which statement made by the client would indicate to the nurse that the client understands the procedure? a. “I must record any symptoms occurring with my activity.” b. “I am not looking forward to staying in bed for 24 hours.” c. “I really am dreading the frequent blood drawing.” d. “I know that I shouldn’t get close to my microwave oven.”
  4. A 9 - year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report? a. Refuses to eat her favorite meals at home. b. Drinks more soft drinks than previously. c. Voids only one or two times per day. d. Gained 10 pounds within one month.
  5. The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.7 mg/dl; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy who has a white blood cell count of 15,000 mm^3. What intervention should the nurse implement? a. Increase Client A's oxygen to 4 liters per minute via nasal cannula. b. Determine if Client B has two units of packed cells available in the blood bank. c. Ask the dietician to add a banana to Client C's breakfast tray. d. Inform Client D that surgery is likely to be delayed until the infection is treated.
  1. A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has "little reason to live." She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement? a. Encourage the client to remove the gun from her possession. b. Notify the client's healthcare provider of the availability of the weapon. c. Contact a person of the client's choosing to remove the weapon from the home. d. Call the local police department and have the weapon removed from the home.
  2. It is most important for the registered nurse (RN) who is working on a medical unit to provide direct supervision in which situation? a. A graduate nurse needs to access a client's implanted port to start an infusion of Ringer's Lactate. b. A postpartum nurse pulled to the unit needs to start a transfusion of packed red blood cells. c. A practical nurse is preparing to assist the healthcare provider with a lumbar puncture at the bedside. d. An unlicensed assistive personnel is preparing to weigh an obese bedfast client using a bed scale.
  3. A nurse is completing the health history for a 25-year-old male client who reports that he is allergic to penicillin. Which question should the nurse ask after receiving this information? a. "Are you allergic to any other medications?" b. "How often have you taken penicillin in the past?" c. "Is anyone else in your family allergic to penicillin?" d. "What happens to you when you take penicillin?"
  4. A 10 - year-old child with meningitis is suspected of having diabetes insipidus. In evaluating the child's laboratory values, which finding is indicative of diabetes insipidus? a. Decreased urine specific gravity. b. Elevated urine glucose. c. Decreased serum potassium. d. Increased serum sodium.
  5. A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating? a. Administer sargramostim (Leukine, Prokine). b. Infuse PRBC and platelet transfusions. c. Give parental prophylactic antibiotics. d. Maintain a protective isolation environment.
  6. A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP - 1, SVR 1600. What nursing action has the highest priority? a. Apply a hypothermia unit to stabilize core temperature. b. Increase the client's IV fluid rate to 200 ml/hr. c. Call the hospital chaplain to counsel the family.
  1. A client who has Type 1 diabetes and is at 10 - weeks gestation comes to the prenatal clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the time. What action should the nurse take first? a. Check the blood glucose level. b. Draw blood for a Hemoglobin A1C. c. Assess urine for ketone levels. d. Provide the client with a protein snack.
  2. A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? a. Administer oxygen via face mask. c. Notify the operating room team. b. Place the client in Trendelenburg. c. Administer a fluid bolus of 500 ml.
  3. The nurse is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention? a. Weigh the child daily. b. Observe the lower extremities for pitting edema. c. Measure the child's abdominal girth weekly. d. Weigh the child's wet diapers.
  4. The mother of a 9 - month-old who was diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day. What response should the nurse provide this mother? a. The child can be around other children but should wear a mask at all times. b. The child will no longer be contagious, no need to take any further precautions. c. Make sure there are no children under the age of 6 months around the infected child. d. Do not expose other children. RSV is very contagious even without direct oral contact.
  5. A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 a.m. and the nurse is running behind schedule. Which medication should the nurse administer first? a. Piperacillin/tazobactam (Zosyn) in 100 ml D 5 W, IV over 30 minutes q8 hours. b. Vancomycin (Vancocin) 1 gm in 250 ml D 5 W, IV over 90 minutes q12 hours. c. Pantoprazole (Protonix) 40 mg PO daily d. Enoxaparin (Lovenox) 40 mg subq q24 hours.
  6. Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy? a. Administer an antiemetic before starting the chemotherapy. b. Instruct the client to drink plenty of fluids during the treatment. c. Keep the head of the bed elevated until the treatment is completed. d. Monitor the client's intravenous site hourly during the treatment.
  1. An elderly male client reports to the clinic nurse that he is experiencing increasing nocturia with difficulty initiating his urine stream. He reports a weak urine flow and frequent dribbling after voiding. Which nursing action should be implemented? a. Obtain a urine specimen for culture and sensitivity. b. Encourage the client to schedule a digital rectal exam. c. Advise the client to maintain a voiding diary for one week. d. Instruct the client in effective techniques to cleanse the glans penis.
  2. The nurse is performing an admission physical assessment of a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider? a. Heel stick glucose of 65 mg/dl. b. Head circumference of 35 cm (14 inches). c. Widened, tense, bulging fontanel. d. High-pitched shrill cry.
  3. Which client's laboratory value requires immediate intervention by a nurse? a. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7 grams. b. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl yesterday. c. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value. d. A client with cancer who has an absolute count of neutrophils < 500 today and had 2,000 yesterday.
  4. In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding? a. 4+ pitting edema of both lower extremities. b. A Braden risk assessment scale rating score of ten. c. Warm, dry skin with a fever of 100° F. d. Hypoactive bowel sounds with infrequent bowel movements.
  5. The healthcare provider prescribes naproxen (Naprosyn) 500 mg PO twice a day for a client with osteoarthritis. During a follow-up visit one month later, the client tells the nurse, "The pills don't seem to be working. They are not helping the pain at all." Which factor should influence the nurse's response? a. Noncompliance is probably affecting optimum medication effectiveness. b. Drug dosage is inadequate and needs to be increased to four times a day. c. The drug needs 4 to 6 weeks to reach therapeutic levels in the bloodstream. d. NSAID response is variable and another NSAID may be more effective.
  6. A nurse is interested in studying the incidence of infant death in a particular city and wants to compare that city's rate to the state's rate. What state resource is most likely to provide this information? a. Disease registry. b. Department of Health. c. Bureau of Vital Statistics. d. Census data.
  1. Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse? a. An adult who had a colon resection yesterday and has an IV. b. An older adult who has a fever of unknown origin. c. A woman who had an acute brain attack (stroke, CVA) 6 hours ago. d. A teenager with a femoral fracture who is in traction.
  2. A primipara at 38 - weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures? a. Chorionic villi sampling under ultrasound. b. Amniocentesis and fetal monitoring. c. Ultrasonography and nonstress test. d. Oxytocin challenge test and fetal heart rates.
  3. A male client who is in the day room becomes increasingly angry and aggressive when he is denied a day-pass. Which action should the nurse implement? a. Tell him he can have a day pass if he calms down. b. Put the client's behavior on extinction. c. Decrease the volume on the television set. d. Instruct the client to sit down and be quiet.
  4. A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the most likely reason for the nurse's behavior? a. The nurse is stating disapproval of the statement. b. The nurse is respecting the client's loss. c. Silence is reflecting the client's sadness. d. Silence allows the client to reflect on what was said.
  5. An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7 - pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the charge nurse implement first? a. Notify the healthcare provider of the assessment findings. b. Determine if the client received anesthesia during delivery. c. Assign a practical nurse (PN) to reassess the client's vital signs. d. Obtain a STAT hemoglobin and hematocrit.
  6. In developing a care plan for a client that has a chest tube due to a hemothorax, the nurse should recognize that which intervention is essential? a. Keep the arm and shoulder of the affected side immobile at all times. b. Ensure that there is no fluctuation in the water-seal chamber. c. Encourage the client to breathe deeply and cough at frequent intervals. d. Maintain the Pleuravac® slightly above the chest level.
  1. Immediate postoperative nursing care for a client who has had a surgical repair of an abdominal aortic aneurysm should include which interventions? a. Assessing pedal pulses frequently and monitoring the nasogastric drainage. b. Maintaining strict bedrest for 72 hours and assessing radial pulses. c. Monitoring an infusion of IV heparin and checking the PTT level daily. d. Assessing the right flank dressing and monitoring the suprapubic Foley catheter.
  2. A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration? a. Exhale forcefully into the tubing for 3 to 5 seconds. b. Inspire deeply and slowly over 3 to 5 seconds. c. Breathe into the spirometer using normal breath volumes. d. Perform IS breathing exercises every 6 hours.
  3. A 65 - year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed by the healthcare provider. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided. What is the legal status of the nurse? a. The nurse is guilty of negligence and will be sued. b. The client would not be able to prove malpractice in court. c. The nurse is protected by the Good Samaritan Act. d. The healthcare provider should have given the morphine sulfate dose.
  4. A client with which problem requires the most immediate intervention by the nurse? a. Finger paresthesias related to carpal tunnel syndrome. b. Increasing sharp pain related to compartment syndrome. c. Increasing burning pain related to a Morton's neuroma. d. Increasing sharp pain related to plantar fascitis.
  5. The charge nurse should intervene when what behavior is observed? a. Two staff members are overheard talking about a cure for AIDS outside a client's room. b. A hospital transporter is reading a client's history and physical while waiting for an elevator. c. A UAP tells a client, "It's hard to quit drinking but Alcoholic Anonymous helped me." d. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge.
  6. Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy? a. Client denies allergies to contrast media. b. Skin prep to insertion site completed. c. On-call sedation administered. d. Oxygen at 2 L/minute per nasal cannula.
  1. A 5 - year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? a. Initiate normal saline IV at 50 ml/hr. b. Administer a loading dose of penicillin IM. c. Obtain a culture of any sputum or wound drainage. d. Administer the initial dose of folic acid PO.
  2. A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Before being discharged, the nurse should provide the client with what instruction? a. Keep the left leg in a dependent position. b. Apply heat to the left leg cast. c. Do not attempt to scratch the skin under the cast. d. Apply a cold pack to any "hot spots" on the cast.
  3. A client has 2 nd^ degree electrical burns on both upper extremities. The nurse is preparing to administer the first application of the topical antimicrobial agent mafenide acetate (Sulfamylon) to the burned area. Which intervention should the nurse implement first? a. Premedicate the client prior to applying the medication. b. Use sterile gloves when applying this medication. c. Cleanse the burned area with sterile normal saline. d. Assess the client's most recent arterial blood gas test results.
  4. The community health nurse must provide a primary prevention program in the community. Which type of program addresses this need? a. Provide a nurse-practitioner to prescribe medications for clients with heart disease. b. Arrange cardiac-prudent diets to be delivered to individuals using Meals on Wheels. c. Incorporate an exercise program at a local Hispanic community center. d. Conduct a weekly blood pressure screening at the Hispanic senior citizen center.
  5. The nurse is conducting assessments at the beginning of the shift. Which client is most likely to have an increased blood pressure since the last set of vital signs was recorded four hours ago? a. A young female with increased urinary output following administration of IV furosemide (Lasix). b. A middle-aged male receiving prazosin hydrochloride (Minipress). c. An elderly male who received two units of packed red blood cells (RBCs). d. An adolescent who is receiving azathioprine (Imuran) following a cardiac transplant.
  6. A client is hemiplegic following a cerebrovascular accident. To prevent this client from experiencing a painful shoulder, what intervention should the nurse include in the plan of care? a. Exercise the affected shoulder by using it when assisting the client out of bed. b. Position the affected arm on pillows while the client is seated in a chair. c. Keep the client's affected arm elevated above the level of the heart. d. Avoid range of motion exercises on the affected shoulder until pain in the shoulder has passed.
  1. The pharmacist enters the wrong dose of a medication when transcribing prescriptions to a client's medication administration record (MAR). Which action should the nurse take to prevent a medication error from occurring? a. Compare the medication label with the medication administration record (MAR). b. Check the client's identification bracelet prior to administering the medication. c. Compare the medication administration record (MAR) to the prescription. d. Verify the room number on the medication administration record (MAR).
  2. While on the delivery table, a primipara tells the nurse that she wishes to breastfeed her infant. To assist the new mother with her goal, which intervention is best for the nurse to implement? a. Permit privacy for the mother and infant to bond. b. Assist the mother to elicit a rooting reflex in the infant. c. Place a small amount of glucose water on the breast. d. Evaluate the infant's sucking reflex then give the infant to the mother.
  3. A male client diagnosed with gastroesophageal reflux (GERD) often wakes up at night experiencing heartburn. He tells the nurse that he sleeps with the head of the bed on blocks, and always drinks a glass of milk at bedtime to help him fall asleep. How should the nurse respond? a. "Milk does contain tryptophan, which helps many people fall asleep." b. "Drinking milk before bedtime can increase your symptoms at night." c. "A warm drink, such as hot tea or cocoa should be substituted for the milk." d. "Taking an antispasmodic medication with the milk will reduce the symptoms."
  4. A client diagnosed with Type 1 diabetes is NPO for a diagnostic test. The nurse is preparing to administer 24 units of 70/30 insulin. Which intervention should the nurse implement first? a. Administer the insulin subcutaneously in the client's abdomen. b. Administer the insulin when the client returns from the test. c. Contact the healthcare provider to adjust the insulin dose. d. Call the department and request that this client's test be done first.
  5. The nurse teaching a preconception preparation class is discussing ways to improve dietary folic acid intake. Which evening snack contains the most folic acid? a. Toasted white bread with butter. b. Whole grain cereal and milk. c. Hard-boiled egg and juice. d. Vanilla milkshake with protein supplement.
  6. A 36 - year-old client is admitted to the ICU following a six-hour surgery to repair a fractured pelvis, and the estimated intraoperative blood loss (EBL) was 3,000 ml. Current client data include: BP 85/70, heart rate 140 beats/minute, urine output 10 ml/hr, PAWP 2, RAP - 3, Hct 20%, Hgb 7 g/dl. What action should the nurse take at this time? a. Administer propranolol (Inderal) to decrease the heart rate. b. Infuse blood and IV fluids to correct the hypovolemia. c. Start a dopamine (Intropin) infusion to raise the BP. d. Draw serum blood cultures to check for infection.
  1. The nurse administers nalbuphine (Nubain) to a postoperative client. What etiology, secondary to the medication's effects, places the client at risk for injury? a. Bleeding complications. b. Adverse CNS effects. c. Electrolyte imbalance. d. Immune system suppression.
  2. A client who has end-stage renal disease (ESRD) continues to be despondent after receiving the biologic response modifier (BRM) epoetin alfa (Epogen, Procrit) for 3 weeks. Which parameters should the nurse assess when evaluating the effectiveness of this BRM? a. WBCs, neutrophil and T 4 count. b. RBCs, hemoglobin, and hematocrit. c. Blood pressure, heart rate, and temperature. d. Serum potassium, calcium, and phosphorus.
  3. A 25 - year-old male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. What is the most important information for the nurse to include in the teaching plan? a. Avoid penile contact with the rectal area. b. Epididymitis is a pre-cancerous condition. c. Obtain an annual prostate digital exam. d. Surgical intervention is often indicated.
  4. A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement? a. Increase the intake of salty foods. b. Administer NaCl supplements. c. Restrict oral fluid intake. d. Hold the client's loop diuretic.
  5. A young adult male is brought to the emergency room with multiple gunshot wounds in the chest, abdomen, and head. After collecting the client's blood-saturated clothing as forensic evidence for the medical examiner, which action should the nurse implement? a. Fold clothing in a large specimen container and send to the pathology lab. b. Roll the clothing in a towel and cover it with an impermeable drape. c. Place the clothes in a paper bag and transfer bag to a red biohazard bag. d. Drop the clothes in a red plastic bag and maintain blood-borne precautions.
  6. A male client asks the nurse how long his hospital stay will be following his scheduled surgery. Which resource provides the best guide for the nurse in responding to the client? a. Critical pathway for the scheduled surgery. b. Diagnosis-related group (DRG) for the surgery. c. The client's preferred provider arrangement. d. Standards of clinical nursing practice.
  7. A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. What is the priority nursing problem for this client? a. Disturbed thought processes. b. Altered sleep pattern. c. Imbalanced nutrition: less than. d. Risk for injury.
  1. The nurse-preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify? a. Warm skin, hypertension, and constricted pupils. b. Bradycardia, hypotension, and respiratory acidosis. c. Mottled skin, tachypnea, and hyperactive bowel sounds. d. Tachycardia, mental status change, and low urine output.
  2. Prior to obtaining an axillary temperature, the nurse should perform which action? a. Check the last oral temperature reading. b. Ask the client when he last ate or drank. c. Place a protective sheath over the thermometer. d. Position the client's arm at heart level.
  3. When is the best time for the nurse to assess a client for residual urine? a. When the client's bladder is distended. b. Immediately after the client voids. c. Just prior to the client voiding. d. After draining the urinary catheter bag.
  4. Which finding should raise the greatest concern for a nurse who is performing an ENT examination? a. A painful ulcerated mucosal area inside the cheek for 1 day. b. Stippled gingival margins that adhere firmly to the teeth. c. A number of small yellowish-white and raised lesions on the buccal mucosa. d. An ulceration under the tongue that has been present for the last three weeks.
  5. During a home visit, the nurse should evaluate the adequacy of a client's treatment for COPD by assessing for which primary symptom? a. Dyspnea b. Tachycardia. c. Unilateral diminished breath sounds. d. Edema of the ankles.
  6. The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene? a. An Asian-American mother reports using cupping to treat infection, resulting in a pattern of red round marks on her toddler's back. b. A Hispanic pregnant client who is often late for appointments, arrives late for today's appointment. c. A Native-American who is being interviewed will not make direct eye contact when asked about violence in the home. d. An African-American infant who is spitting up milk has lost 6 ounces since last week's clinic visit.
  1. A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first? a. Provide a supportive, structured environment for meals. b. Assess weight, vital signs, potassium and other electrolytes. c. Discuss alternative strategies for binging and purging. d. Monitor the client after meals for possible vomiting.
  2. Which symptom in a client with fractured ribs would indicate the presence of an abnormality warranting immediate intervention by the nurse? a. Complaints of chest pain with movement. c. Shallow respirations and refusing to take deep breaths. b. Ecchymosis around fracture site. c. Asymmetrical chest wall excursion.
**A 62 - year old male client with a history of coronary artery disease complains that his heart is** **"racing" and he often feels dizzy. His blood pressure is 110/60, and he uses portable oxygen at** **2 liters per nasal cannula. Based on the rhythm shown, the nurse should administer which** **prescription?** a. Give magnesium per secondary infusion. b. Initiate IV heparin solution per protocol. c. Administer IV adenosine (Adenocard). d. Prepare for synchronized cardioversion.
  1. The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust? a. Explain that distrust is related to feeling anxious. b. Initiate short, frequent contacts with the client. c. Explain that these beliefs are related to her illness. d. Offer to keep the belongings at the nurse's desk.
  2. A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What medication can the nurse expect the healthcare provider to prescribe? a. Nitrofurantoin (Macrodantin) orally. b. Erythropoietin (Epogen) intravenously. c. Kayexalate retention enema. d. Azathioprine (Imuran) orally.
  1. A client with late stage rheumatoid arthritis frequently drops the silverware while eating. Which resource would be of greatest value to this client? a. A UAP to help feed the client. b. An Occupational Therapist. c. A Physical Therapist. d. A Registered Dietician.
  2. The mother of a one-month-old calls the clinic to report that the back of her infant's head is flat. How should the nurse respond? a. Place a small pillow under the infant's head while lying on the back. b. Turn the infant on the left side braced against the crib when sleeping. c. Prop the infant in a sitting position with a cushion when not sleeping. d. Position the infant on the stomach occasionally when awake and active.
  3. During a preoperative appointment at an ambulatory surgery center, a client expresses anxiety to the nurse about the impending surgery. How should the nurse respond? a. "It is very normal to feel anxious before a surgical procedure." b. "Let me sit down with you and explain the surgical procedure." c. "Tell me what concerns you have about your upcoming surgery." d. "Medication will be available if you experience any pain after surgery."
  4. The nurse is planning to administer a Mantoux test to determine if the client has been infected with the tuberculosis bacilli. What is the correct interpretation by the nurse? a. A positive reaction indicates that active disease is present in the body. b. The test should be read within 24 hours of administration. c. Induration noted by inspection and palpation confirms a significant reaction. d. A reaction of 0 to 4 mm is considered significant and requires further investigation.
  5. The nurse is communicating with a 12 - year-old who is hearing impaired. What action is best for the nurse to use when attempting to communicate with this child? a. Convey ideas by writing short sentences. b. Emphasize emotions with facial expressions. c. Attract the child's attention before speaking. d. Use a picture board to communicate needs.
  6. The nurse anticipates the prescription of a reduced dosage of a nephrotoxic medication for the client with which problem? a. Documented presence of a kidney cyst found via ultrasound. b. Observable hematuria following a renal biopsy procedure. c. Subjective reports of dysuria with burning pain and cloudy amber urine. d. Diminished creatinine clearance found after 24 - hour urine collection.