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NUR COMMUNITY HESI EXIT 1 - WITH 100%
ACCURATE SOLUTIONS- 2025
- male client admitted the morning of his scheduled surgery tells the PN that he drank water last night. What intervention will the PN implement first?
Determine the amount of water and exact time it was taken.
- A client receives ondansetron prior to chemotherapy treatment. How should the PN evaluate this medication?
Monitor the client for nausea or vomiting following the treatment.
- During morning rounds a client is admitted with OCD is in the...of the same table. What intervention should the PN implement when approached?
Provide time for the behavior then guide the client to other activities.
- The PN is caring for an older adult client who is confused and spends...factor contributes to an increased risk for impaired skin integrity for this client?
Has increasing episodes of urinary incontinence.
- The PN determines that a client with cirrhosis is experiencing peripheral Take?
Protect the clients’ feet from injury. lOMoARcPSD|
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- A client is admitted to the postoperative surgical unit after a left lobectomy with two chest tubes ..... observes the water-sealed chambers, set and prescribed
suction of 20cm water what
action should the PN implement?
Maintain system integrity and to promote lung expansion.
- Photo of chest and locating apical HR. Just below the left nipple.
- At the end of a 12-hour shift the PN observes the urine in a client’s drainage. What action should the PN take next?
Note the most recent white blood count.
- A client with a compound fracture of the left ankle is being discharged with a below the knee cast PN provide to the client prior to discharge?
Never scratch under the cast.
- Thirty minutes after receiving IV morphine, a postoperative male client continues to rate his pain. what action should the PN implement first?
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Implement complementary pain relief methods.
- A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in ...................................................................................................... with
one or two word responses. The morning the PN observes that he Which intervention is most
important for the PN to implement? Measure appropriate vital signs.
- The PN is assisting an unsteady client to ambulate from the bed to the bath. client loses
balance and falls onto the bedside table. What action should the PN take first? Stay with the client and call for assistance.
- The PN is assisting a female client to obtain a voided specimen for Uri meatus.
Which
intervention is performed next? Initiate the urine stream?
15.................................................................................................................... An 8-
year-old is placed in 90-90 traction for a fractured femur that resulted from
................................................................................................................. further
action by the PN? lOMoARcPSD|
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- A client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 ml per hour is...1200 the PN notes that there are 750 ml of solution remaining. At what time should the nurse expect to discontinue the intravenous therapy?
- The PN is caring for a client who had a total laryngectomy, left radical neck dissection... Client is receiving nasogastric tube feedings via an internal pump. Today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding?
Gastric residual volumes.
- A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take?
Ensure that all the areolar tissue of the nipple is in the infant’s mouth. lOMoARcPSD|
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- Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client?
Deltoid.
- Before inserting medication into a client’s vagina, what instructions should the pn.
Urinate until bladder is empty.
- An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which information is best for the PN to provide?
A history of untreated gonorrhea can lead to PID
- A 28-year-old client is in active labor and complains of a cramp in her leg. What intervention should the PN implement?
Extend the leg and flex the foot?
- A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort?
Wear a supportive bra at all times. lOMoARcPSD|
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- A client with schizophrenia reports auditory hallucinations when admitted to the hospital. PN to include in the assessment of this client?
"What are the voices uttering?"
- A young adult male tells the PN he has declared to change his hours at work so that he can...his community. Which stage of Maslow's development is this young adult attempting to achieve?
Self-actualiztion.
- A female client arrives to the clinic for an annal physical examination. When reviewing...the PN that she takes herbs for high blood pressure instead of the prescribed. Important for the PN to reinforce with the client?
Explain risks associated with using herbs instead of the prescribed antihypertensives.
- A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client “This type…hospital" what intervention should the PN implement?
Act as the clients advocate when discussing the issue with the HCP. lOMoARcPSD|
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- The PN is caring for a client receiving chemotherapy who has thrombocytopenia. Important to include in the nursing care plan?
Watch the client for abnormal bleeding
- A client is transferred to the surgical unit from the intensive care unit after evacuation of bilateral. Primary observation should the PN monitor?
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-Toileting assistance for a client receiving therapy after a total hip replacement
-daily skin care for a client with a descending double barrel colostomy
-morning care for a client with a staph wound infection
- A client is complaining of a tightening sensation in the fingers, nose tip and ear lobes...24...PN should be prepared to implement what measure first?
Obtain prescribed calcium gluconate for tetany.
- A client’s chief complaint is being able to swallow only small bites of solid food...PN should assess for what additional information?
History of alcohol and tobacco use.
- An adult female client with type 1 diabetes mellitus is receiving 35 units of NPH insulin...PN document as evidence that the amount of insulin is inadequate.
Consecutive evening serum glucose readings of >260 mg/dl.
- The PN is assigned the care of four clients on a medical- surgical...prioritize client assessments
-A client who is admitted with a suspected ruptured appendix
-A client who is post-lumbar puncture is reporting a severe headache
-An older male adult with Alzheimer’s who wanders out of his room lOMoARcPSD|
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-A postoperative client who needs reinforcement of discharge instruction lOMoARcPSD|
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- The partner refuses to go. The PN suspects the injuries may be the result of...
Arrange to take the client to the operating room holding area for privacy.
- The PN is caring for a client whose urine drug screen is positive for...exhibit during cocaine withdraw.
Powerful craving for more
- The PN is with a client when the health care provider explains that the tumor. Later in the morning the client asks the PN "What do the letters T, N, M: star for?
The letters stand for tumor size, node involvement, and metastasis.
- Following discharge teaching, a male client with duodenal ulcer tells the nurse he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow- up action by the nurse?
Review with the client the need to avoid foods that are rich in milk and cream. lOMoARcPSD|
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- An adolescent male with severe acne recently started treatment with isotretinoin, a form of Vitamin A. During a follow up clinic appointment, which assessment is most important for the PN to complete?
Ask about occurrence and frequency of nosebleeds
- The PN is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to reinforce in this client plan of care?
Interventions to decrease emotional stress.
- An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the PN, who is taking the client the clients vital signs. What action should the PN implement?
Reinforce the need for extra rest periods and plenty of sleep.
- The PN is completing a focused assessment of a client with acute hepatitis
A. The client reports a constant sense of fatigue. How should the PN respond? Affirm the importance of rest to promote liver healing.
- When the PN plans daily care for a group pf client, which client should the PN see first due to the risk of complication?
-place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the dressed site
-pour warmed sterile solution to an open sterile dressing tray that contained sterile gauze pads
- A male client who is diagnosed with schizophrenia is taking an antipsychotic medication and calls the psychiatric clinic. The client tells the PN that he is achy and stiff, has a temperature of
103.4 F and is sweating. How should the PN respond to this client?
Direct the client to obtain immediate transportation to the emergency center. lOMoARcPSD|
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- The Glasgow coma scale is being used to monitor a client in the critical care unit. The scale is used to evaluate what client status?
Level of conscious.
- A client is diagnosed with hyperthyroidism. Which symptoms should the PN expect this client to exhibit? lOMoARcPSD|
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Muscle cramping and dry flushed skin
- The PN administers an antibiotic to a client with a respiratory tract infection...evaluate the medications effectiveness, which laboratory values should the PN monitor?
B,d ABD.
- To obtain an estimate of a client’s systolic blood pressure, what action should the PN take first?
Palpate the client’s brachial pulse.
- A client reports feeling numbness and tingling in extremities. What action should the PN implement?
Review the client’s serum electrolyte levels.
- Immediately after birth, which nursing intervention has the highest priority for the newborn infant?
Preventing heat loss and neonatal cold stress. lOMoARcPSD|
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- The PN overhears a female client with Cushing’s syndrome tell her family in a very loud and angry voice to leave her room and not come back. The response by the PN is based on recognizing which common manifestation of the syndrome?
Mood alterations.
- A 0800 a client’s apical pulse rate is 98 beats/minute> Four hours later the apical pulse rate is 54 beats/minute. What action should the PN take next?
Determine the level of consciousness.
- After three weeks of antibiotic therapy, a child who weighs 55 pounds develops painful oral lesions, so the heal care provider prescribes acyclovir (Zovirax) 20 mg/kg daily. How many mg should the PN administer to this child?
- The PN is assisting a client to the bathroom after right cataract extraction. The client has an eye shield over the right eye. How should the PN asset the client during ambulation?
Stand in front of the client and lead the client forward to the bathroom. lOMoARcPSD|
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- Which client information is most important for the PN to consider when providing instructions to the UAP about providing morning care to a postoperative client?
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Urinary output of 50 ml/hour.
- A male client who was admitted with gangrene of the right lower extremity is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the PN take first?
Encourage the client’s wife to express concerns.
- After report, the PN receives the laboratory values for four clients. Which client requires the pns immediate intervention?
- The PN views the mid-line episiotomy of a client who reports pain in her stitches. What action should the PN take first?
Observe suture line for separation and hematoma formation.
- A new mother asks the PN about an area of swelling on her baby head that lies across the suture line near the posterior fontanel. How should the PN respond?
Caput succedaneum will be absorbed and causes no problem.
- The PN obtains a finger stick glucose for a client with type 1 diabetes mellitus who is conscious and demonstrating hand tremors and shaking. The PN reports the clients result of 55 mg/dl to the nurse. What action should the PN implement next?
Provide the client with a glass of milk and crackers. lOMoARcPSD|
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- A client who is primigravida at term comes to the prenatal clinic and tells the PN that she is having contractions every 5 minutes. The PN monitors the client for 1 hour using a external fetal monitor and determines that the clients contractions are 7 to 15 minutes apart lasting 20- seconds with mild intensity by palpation. What action should the PN take?
Send the client home and instruct her to call the clinic when her contractions are 5 minutes apart for one hour.
- The PN plans to evaluate an adult’s response to a prescription for colchicine. Last week the client was seen in the clinic for pain in the great left toe, which was the result of an acute attack of gout. Which data should the PN obtain to evaluate the therapeutic effectiveness of this medication?
Pain scale level during walking.
- The PN is caring for a client who was recently diagnosed with hepatitis B virus (HBV). The PN observes that the client’s urine is the color of dark tea. What action should the PN take? Encourage increased oral fluid intake.
- In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the PN take?
Use a gloved finger to rub the suspension over the infected area. lOMoARcPSD|
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- While the PN and UAP are turning a client with an abdominal incision, the client’s incision eviscerates. Which task is best for the PN to assign to the UAP?
Gather supplies.
- A client develops generalized edema associated with chronic kidney disease (CKD). The PN understands the formation of the edema is the result of which physiological process?
Plasma protein losses resulting in decreased oncotic pressure within the vessels. 92.The PN and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement?
Demonstrate to the UAP how to approach the client from the clients left side.
- An older adult female is admitted with syncope and laboratory findings indicate that her hemoglobin is 8.0 grams /dl. She has a recent history of headaches and frequent falls. Admission prescription orders include continuation of all home medications. Which medication should the PN withhold until consulting with the charge nurse?
Aspirin. lOMoARcPSD|
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- The PN is planning care for a client who has generalized tonic colonic seizures and is vomiting and having frequent diarrhea stools. To reduce the risk of injury to this client which nursing measurements should the PN implement?
Axillary temperatures and padded side rails.
- When assessing an adult male who present at the community health clinic with a history of hypertension the nurse notes that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflux disease and depression.
Which interventions is most important for the PN to implement? Review the clients use of over the counter (OTC) medications.
- A client with Alzheimer’s disease (AD) is receiving trazadone (Desyrel) a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client’s mood and sleep patterns are improved but there is no change in cognitive ability. How should the nurse respond to this information?
- A client with type 2 diabetes becomes unresponsive and says I'm not feeling right which action should the PN take?
Give 4 ounces of apple juice.
- A new mother is breastfeeding her newborn for the first time and complains of nipple pain when the baby sucks. What should the nurse tell the mom?
Ensure that all the areola tissue of the nipple is in the infant’s mouth.
- A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug? Provide oral care.
- The PN is caring for a client in bucks’ tract what is the priority goal for the client in traction?
Maintain straight body alignment. lOMoARcPSD|
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- Which site should the PN use when administering RHO D. Deltoid.
- Client with Huntington’s disease starts jerking around while the family is there what should the PN do?
Offer emotional support to the family.
- When should a person use additional birth control precautions?
When taking antibiotics for an infection.
- Client who has four gold seed implants on a chest wall tumor is on radiation precautions what basic precautions should the PN nurse observe when administering direct client care?
Minimal time maximum distance and protective shielding.
- Client voiding small amounts every 24 hours
The catheterized volume determines the need to reinsert the indwelling catheter.
- Based on the principle of asepsis the PN should consider which situation to be sterile?
An open Foley catheter kit set up on a table at the PN waist level. lOMoARcPSD|
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- A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client?
Measure all emesis accurately.
- Single mother of a child with head injury comes crying to the clinic what should the PN tell her?
This must seem overwhelming to you right now.
- On admission to the medical unit a client who is homeless and has a history of HIV with persistent cough?
Erythema and indurations of 5mm at site.
- When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given In the computer. What action should the PN take?
Contact the medication nurse to clarify the findings. lOMoARcPSD|
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- The hearing of ringing in the ears what medication should be reported to the Health provider?
Gentamicin.
- 28-year-old client is in active labor and complains of a cramp in her leg. What intervention should the PN implement?
Extend the leg and flex the foot.
- A client is admitted for observation after experiencing a TIA. High risk for injury.
- Which picture of nailbeds indicate hypoxia?
-body temp
- During morning report the PN learns that an assigned client has phlebitis from an intravenous access device. What manifestations will the PN assess in this client?
Palpable cord along the vein.
- While measuring an orthostatic blood pressure the client becomes dizzy. What would the PN do?
Assist the client to site down.
- Why does the PN wear a pair of clean gloves when providing care to a client with clostridium difficile?
To protect the nurse from microorganisms that is within the client.
- A client with lower back pain has been prescribed a transcutaneous electrical nerve stimulator (TENS) unit for pain control. Why would the client be instructed to use this device on the low frequency setting?
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Stimulate serotonin levels.
- The PN is reviewing actions for a mother to take to prevent her toddler from being injured in the home. What will the PN emphasize with this mother?
Keep poisonous and other materials locked away.
- How should the PN assist the client to provide sputum sample?
Coach the client to take deep breaths and cough deeply to mobilize secretions.
- A client with a fever is diaphoretic and the linens are saturated. After assessing the clients’ vital signs, which action would the PN take?
Change the bed linens.
- The mother of a toddler demonstrating a sudden onset of stridor says that the child was playing with an old shirt and suddenly could not breathe very well. What would the PN suspect has occurred with this client?
The child aspirated a button from the shirt. lOMoARcPSD|
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- The PN has identified the howling statement as a desired outcome for a client "client will report effective pain management when using analgesic medication every 6 hours as prescribed." This outcome statement would be appropriate for which client problem?
Ineffective pain management.
- A client recovering from surgery to the fibula has bleeding on the cast. The PN outlines the border of bleeding to serve at a baseline. Which action would the PN do next?
Recheck the cast within the next 15 minutes.
- A client who received 10 units of regular insulin is diaphoretic and is shaky. Why would the PN provide the client with graham crackers and milk?
The client is experiencing hypoglycemia.
- A client with multiple sclerosis has developed a bladder infection. What would the PN identify as a possible cause for this infection? Immunosuppressant therapy.
- Why does the PN administer ophthalmic ointment in the eyes of a newborn?
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To prevent gonorrheal or chlamydial ophthalmic infections.
- A 40-year-old client has obtained a baseline mammogram. When would the PN recommend that the next mammogram be performed?
In 1 year.
- The PN assesses a moon-shaped face and muscle wasting in a client receiving dexamethasone (Decadron). What will these manifestations suggest to the PN?
