NR 340 HESI Final Exam Critical Care Nursing

Multiple Choice (160 Questions)Identify the letter of the choice that best completes the statement or answers the question.
  1. Question: 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?
  2. Question: 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?
  3. Question: 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?
  1. Question: A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective?
  2. Question: 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?
  1. Question: 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?
  2. Question: Which signs or symptoms are characteristic of an adult client diagnosed with Cushing’s syndrome?
  3. Question: 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
  4. Question: 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?
  5. Question: 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?
  6. Question: The nurse is administering sevelamer (RenaGel) during lunch to a client with end stage renal disease (ESRD). The client asks the nurse to bring the medication later. The nurse should describe which action of RenaGel as an explanation for taking it with meals?
  7. Question: The nurse formulates a nursing diagnosis of, “High risk for ineffective airway clearance” for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?
  8. Question: Following a CVA, the nurse assess that a client developed dysphagia, hypoactive bowel sounds and firm, distended abdomen. Which prescription for the client should the nurse question?
  9. Question: A client’s telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate?
  10. Question: In assessing a 70-year-old female client with Alzheimer’s disease, the nurse notes that she has deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client’s plan of care?
  11. Question: A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response?
  12. Question: 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?
  1. Question: The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. What information should the nurse provide?
  2. Question: 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?
  3. Question: A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report?
  4. Question: 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 mm3. What intervention should the nurse implement?
  5. Question: 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?
  6. Question: It is most important for the registered nurse (RN) who is working on a medical unit to provide direct supervision in which situation?
  7. Question: 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?
  8. Question: 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?
  9. Question: 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?
  10. Question: 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?
  11. Question: 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?
  12. Question: 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?
  13. Question: The nurse is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention?
  14. Question: 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?
  1. Question: 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?
  1. Question: Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?
  2. Question: 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?
  3. Question: 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?
  4. Question: Which client’s laboratory value requires immediate intervention by a nurse?
  5. Question: In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding?
  6. Question: 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?
  7. Question: 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?
  8. Question: A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client?
  9. Question: A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety?
  10. Question: What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
  11. Question: The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statement should the nurse provide?
  12. Question: A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?
  13. Question: A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a Level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per minute. Which drug is the transport team most likely to administer to this infant?
  14. Question: 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?
  15. Question: 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?
  16. Question: 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?
  17. Question: 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?
  18. Question: 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?
  1. Question: 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?
  2. Question: Immediate postoperative nursing care for a client who has had a surgical repair of an abdominal aortic aneurysm should include which interventions?
  3. Question: 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?
  4. Question: 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?
  1. Question: A client with which problem requires the most immediate intervention by the nurse?
  2. Question: The charge nurse should intervene when what behavior is observed?
  3. Question: Which assessment finding indicates a client’s readiness to leave the nursing unit for a bronchoscopy?
  4. Question: The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?
  5. Question: An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client?
  6. Question: A client with a cold is taking the antitussive benzonatate (Tessalon). Which assessment data indicates to the nurse that the medication is effective?
  7. Question: The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first?
  8. Question: The nurse is caring for a client whose urine drug screen is positive for cocaine. What behavior is this client likely to exhibit during cocaine withdrawal?
  9. Question: The nurse enters the room of a client with a history of seizure activity and observes that the unlicensed assistive personnel (UAP) is securing several pillows against the side rails to protect the client. What action should the nurse implement?
  10. Question: 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?
  11. Question: 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?
  12. Question: A client has 2nd 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?
  1. Question: The community health nurse must provide a primary prevention program in the community. Which type of program addresses this need?
  2. Question: 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?
  3. Question: 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?
  1. Question: 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?
  2. Question: 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?
  3. Question: 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?
  4. Question: 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?
  5. Question: The nurse teaching a preconception preparation class is discussing ways to improve dietary folic acid intake. Which evening snack contains the most folic acid?
  6. Question: 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?
  7. Question: An unresponsive female victim of a motor vehicle collision is brought to the emergency department where it is determined that immediate surgery is required to save her life. The client is accompanied by a close friend, but no family members are available. What action should the nurse take?
  8. Question: Following a motor vehicle collision, a 3-year-old girl has a spica cast applied. Which toy is best for the nurse to provide for this 3-year-old child?
  9. Question: While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witnesses the event take?
  10. Question: After placing a 36-week-gestation newborn in an isolette and drying the infant with several blankets, what should the nurse implement next?
  11. Question: A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement?
  12. Question: The nurse learns that a newly admitted adult client has a six month history of recurring somatic pain. During the admission interview, it is most important for the nurse to question the client about what problem ?
  13. Question: The nurse administers nalbuphine (Nubain) to a postoperative client. What etiology, secondary to the medication’s effects, places the client at risk for injury?
  14. 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?
  1. Question: 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?
  2. Question: 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?
  3. Question: 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?
  4. Question: 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?
  5. Question: 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?
  1. Question: 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?
  2. Question: Prior to obtaining an axillary temperature, the nurse should perform which action?
  3. Question: When is the best time for the nurse to assess a client for residual urine?
  4. Question: Which finding should raise the greatest concern for a nurse who is performing an ENT examination?
  5. Question: During a home visit, the nurse should evaluate the adequacy of a client’s treatment for COPD by assessing for which primary symptom?
  6. Question: The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene?
  7. Question: When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client’s vital signs are within normal limits. He reports feeling “out of breath” but denies any other complaints. What action should the nurse take at this time?
  1. Question: The nurse observes that a client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement?
  2. Question: A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client’s need at this time?
  3. Question: The charge nurse observes that a client with a nasogastric tube applied to low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel 99. Which assessment is most important for the nurse to complete to determine a client’s tolerance for ambulation?
  4. Question: 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?
  5. Question: Which symptom in a client with fractured ribs would indicate the presence of an abnormality warranting immediate intervention by the nurse?
  6. Question: 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?
  7. Question: 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?
  8. Question: 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?
  9. Question: A client with late stage rheumatoid arthritis frequently drops the silverware while eating. Which resource would be of greatest value to this client?
  10. Question: 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?
  11. Question: 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?
  12. Question: 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?
  13. Question: 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?
  14. Question: The nurse anticipates the prescription of a reduced dosage of a nephrotoxic medication for the client with which problem?
  15. Question: The nurse is assessing a client’s central venous pressure (CVP) via a pulmonary artery (PA) catheter port. The client is in a supine position with the head of the bed at a 45 degree angle. The CVP reading is 6 mmHg higher than the previous reading. To evaluate the reading, what action should the nurse take first?
  16. Question: While inserting an indwelling urinary catheter in a female client, the nurse observes urine flow in the tubing. What action should be taken next?
  17. Question: The first time a male client stands at the bedside following a total hip replacement, he reports severe pain in his left calf. What intervention should the nurse take first?
  18. Question: A 10-year-old boy is admitted to Neuro Intensive Care following a supratentorial craniotomy. What postoperative intervention should the nurse plan to implement?
  19. Question: …….. finding in an elderly female client who was started on digoxin (Lanoxin) 0.25 mg indicates that the medication is producing a therapeutic effect?
  20. Question: The nursing diagnosis, “High risk for infection” is most relevant for a client with which hematologic problem?
  21. Question: …….. alarm of a client’s pulse oximeter sounds and the nurse notes that the oxygen saturation rate is indicated at 85%. What action should the nurse take first?
  22. Question: A client admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test?
  23. Question: Following a traumatic delivery, an infant receives an initial Apgar of 3. What intervention is most important for the nurse to implement?
  24. Question: After administering the initial dose of enalapril (Vasotec) to a female client, it is most important for the nurse to assist the client with which activity?
  25. Question: The charge nurse working on a rehabilitation unit is making client assignments for 2 registered nurses (RN) that have been in the department over 3 years, and one new RN graduate who completed orientation this week. Which client should the charge nurse assign to the new RN graduate?
  1. Question: A client has a new prescription for the maximum recommended dosage of piperacillin/tazobactam (Zosyn) for nosocomial pneumonia. The nurse should report which laboratory finding to the healthcare provider before administering the prescribed dose?
  1. Question: In teaching a client with Parkinson’s disease, the nurse describes what rationale for the prescription of levodopa-carbidopa (Sinemet)? This drug
  2. Question: A male client who has been immobilized for four days because of multiple broken bones following a motor vehicle collision is admitted from the intensive care unit to the medical unit of an acute care hospital. What assessment data are most important for the nurse to obtain within the first hour of admission?
  3. Question: Which finding should the nurse expect a client to exhibit who is newly diagnosed with fibromyalgia?
  4. Question: An alert and oriented client requiring droplet precautions is placed in a private room at the end of the hallway. Several days later, the nurse finds that the client is restless and anxious. What action should the nurse implement?
  5. Question: The nurse is performing an admission assessment on an HIV positive client with a diagnosis of Pneumocystis carinii pneumonia (PCP). The nurse should carefully observe the client for which symptoms?
  6. Question: A 3-year-old with HIV infection is staying with a foster family who is caring for three other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first?
  7. Question: The healthcare provider prescribes an excessive amount of morphine sulfate IV push to be given to a terminally ill client. What is the priority intervention for the nurse to implement?
  8. Question: A 2-year-old child with celiac disease experiences a relapse of symptoms. In developing a teaching plan for the child’s family, which topic should be the nurse’s primary focus?
  9. Question: Which client situation requires the most immediate intervention by the nurse?
  10. Question: A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first?
  1. Question: An 84-year-old female resident of an assisted living center has become increasingly withdrawn from her friends, cries often, and asks the nurse to call her daughter three times a day. The nurse’s plan of care should be based on the knowledge that the resident is exhibiting behaviors consistent with which of Erikson’s stages?
  2. Question: The nurse assesses an adult client who has a sigmoid colostomy following a bowel exploration performed yesterday. Which assessment finding should be reported to the surgeon immediately?
  3. Question: A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to what volume of fluid?
  4. Question: The charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one registered nurse (RN) with 10 years experience, one RN with 5 years experience, and a new graduate RN who just completed a 12-week internship. Which client should the nurse assign to the new graduate RN?
  5. Question: The mental health nurse working in a community treatment center is preparing an educational presentation on medication administration, and plans to use photographs of clients to demonstrate certain medication principles. Which intervention is most important for the nurse to implement?
  6. Question: The nurse enters a male client’s room to administer a subcutaneous dose of enoxaparin sodium (Lovenox), a low molecular weight heparin. The client is lying supine in bed. What action should the nurse implement?
  7. Question: A high-school girl asks the school nurse what to do about her fingernails that look “so awful” since she had her artificial nails removed 6 weeks ago. On inspection, the nurse finds the girl’s nails are thickened, cracked, and yellowing. What instruction should the nurse provide?
  8. Question: The nurse identifies a priority diagnosis of, “Altered comfort related to menstrual cramps” for a 25-year-old female client. Which self-care activity should the nurse emphasize in the client’s teaching plan?
  9. Question: A client receiving warfarin (Coumadin) develops hematuria. What is the priority nursing action?
  10. Question: While making a home visit, the nurse observes that a male client who is on a sodium restricted diet is drinking herbal tea and using a salt substitute to flavor his breakfast of scrambled eggs and smoked ham. What instruction should the nurse provide?
  11. Question: While administering a pneumococcal vaccine to an older adult, the nurse provides teaching about methods to prevent pneumonia. Which instruction should the nurse include?
  12. Question: A male client with chronic pain reports minimal pain relief despite attempts to adhere to the pain relief measures he was taught. He appears withdrawn and refuses to be involved with planning his care. The nurse should identify which problem as having the highest priority?
  13. Question: The nurse is supervising an unlicensed assistive personnel (UAP) who is preparing to provide catheter care for a client with an indwelling urinary catheter. The UAP has obtained sterile gloves and the supplies needed to clean the area. What action should the nurse take?
  14. Question: The RN case-manager working in a home health care agency is making client assignments. Which client should the case-manager assign to a newly hired RN with 3 years acute care experience? The client
  15. Question: A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency room with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?
  16. Question: A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7-pound infant four hours ago by cesarean delivery. Which nursing diagnosis has the highest priority?
  17. Question: A male client’s lithonate (Lithium) prescription was increased a month ago, and his current lithium level is 0.54 mEq/L. When calling the client to report the laboratory findings, which question is most important for the nurse to ask?
  18. Question: The nurse is pouring a bottle of sterile solution into a container on a sterile field that is set up on a client’s bedside table. Which action is in keeping with the principles of surgical asepsis?
  19. Question: A client who had a left above knee amputation (AKA) two days ago has a soft stump dressing in place. To prevent the development of a contracture on the left leg, which intervention should the nurse implement?
  20. Question: The nurse overhears two hospital employees discussing confidential client information in the cafeteria. The nurse decides to intervene, because this situation is a breach of which ethical principle?
  21. Question: A middle-aged female client is admitted to the Emergency Department after fainting while working outside and perspiring on a hot summer day. Assessment findings indicate that she is tachycardic with a blood pressure of 96/68, and her serum sodium level is 128 mEq/L. Which prescription should the nurse implement first?
  22. Question: Following a total thyroidectomy, the nurse plans to observe a client for complications; in particular, for development of hypoparathyroidism. What finding indicates that the client has developed this complication?
  23. Question: A 30-year-old female client with a history of fibrocystic breast disease is seeking care because of a pea-sized, painful lump she discovered in her left breast three weeks ago. She is anxious, and states that she is sure she has cancer. Which response is best for the nurse to provide?
  24. Question: A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety?
  25. Question: Ampicillin (Ampicin) 1 gram IV q4h is prescribed for a 38 week multipara how is positive for Group B streptococcus. The drug is available via the Ptyxis system diluted in 50 ml of normal saline. To admister the medication over 30 minutes, the nurse should set the infusion pump to deliver how many ml/hr? (Enter numerical value only)
  26. Question: A client weighing 176 pounds is started on a weight-based heparin protocol. The pharmacy provides 500 ml D5W with 25,000 units of heparin. The sliding scale prescription reads: “Begin the infusion for the client weighing 74-80 kg to infuse at 1000 units/hr; more than 80 kg infuse at 1,200 units/hr; less than 74 kg infuse at 800 ml/hr.” The nurse should regulate the infusion pump at how many ml/hour? (Enter numerical value only.)
  27. Question: The nurse plans to administer two preoperative medications to a client in a single syringe. The prescription is for meperidine (Demerol) 75 mg and promethazine (Phenergan) 25 mg. The Demerol is contained in a vial labeled 100 mg/ml, and the Phenergan is in a vial labeled, “25 mg/ml.” How many total ml will the syringe contain that the nurse administers to this client? (Enter numerical value only. If rounding is required, round to the nearest hundredth.)
  28. Question: A 16-year-old male is admitted after a motor vehicle collision with 50% burns over his body. One liter of normal saline is prescribed to infuse over 4 hours. The drop factor is 60 drops per ml. The nurse should regulate the infusion to administer how many drops per minute? (Enter numerical value only.)

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