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2025 HESI Exit Exam|160 Questions With Correct Answers Latest Update,., Exams of Nursing

2025 HESI Exit Exam|160 Questions With Correct Answers Latest Update, .2025 HESI Exit Exam|160 Questions With Correct Answers Latest Update,.

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2025 HESI Exit Exam|160 Questions With
Correct Answers Latest Update,.
A female client presents in the emergency department and tells the nurse that she was
raped last night. Which question is most important for the nurse to ask?
A. Has she taken a bath since the rape occurred?
B. Is the place where she lives a safe place?
C. Does she know the person who raped her?
D. Did she report the rape to the police department? - Correct answerA. Has she
taken a bath since the rape occurred?
The nurse is completing the admission assessment of a 3-year old who is admitted with
bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the
child is experiencing increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope - Correct answerB. Sluggish and
unequal pupillary responses
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an
elevated serum amylase. Which additional information is the client most likely to report
to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly. - Correct answerA.
Abdominal pain decreases when lying supine
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the
hospital. Which information is most important for the nurse to provide the parents prior
to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family - Correct answerA.
Instructions about how much fluid the child should drink daily
To auscultate for a carotid bruit, the nurse places the stethoscope at what location.
(Select the location on the image with a red dot). - Correct answerI placed the red
dot on the base of the neck on the right side
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Download 2025 HESI Exit Exam|160 Questions With Correct Answers Latest Update,. and more Exams Nursing in PDF only on Docsity!

2025 HESI Exit Exam|160 Questions With

Correct Answers Latest Update,.

A female client presents in the emergency department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? A. Has she taken a bath since the rape occurred? B. Is the place where she lives a safe place? C. Does she know the person who raped her?

D. Did she report the rape to the police department? - Correct answer A. Has she

taken a bath since the rape occurred? The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)? A. Tachycardia and tachypnea B. Sluggish and unequal pupillary responses C. Increased head circumference and bulging fontanels

D. Blood pressure fluctuations and syncope - Correct answer B. Sluggish and

unequal pupillary responses A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse? A. Abdominal pain decreases when lying supine B. Pain lasts an hour and leaves the abdomen tender C. Right upper quadrant pain refers to right scapula

D. Drinks alcohol until intoxicated at least twice weekly. - Correct answer A.

Abdominal pain decreases when lying supine A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A. Instructions about how much fluid the child should drink daily. B. Signs of addiction to opioid pain medications C. Information about non-pharmaceutical pain relief measures

D. Referral for social services for the child and family - Correct answer A.

Instructions about how much fluid the child should drink daily To auscultate for a carotid bruit, the nurse places the stethoscope at what location.

(Select the location on the image with a red dot). - Correct answer I placed the red

dot on the base of the neck on the right side

After receiving report on an inpatient acute care unit, which client should the nurse assess first? A. The client with an obstruction of the large intestine who is experiencing abdominal distention B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal

rigidity - Correct answer D. The client with a bowel obstruction due to a volvulus

who is experiencing abdominal rigidity A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis

D. Respiratory alkalosis - Correct answer D. Respiratory alkalosis

A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position? A. Supine B. supine; feet elevated higher than head C. supine; head elevated higher than feet

D. Fowlers - Correct answer Fowlers

The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? (Select all the apply) A. Frequent syncope B. Occasional nocturia C. Flat affect D. Blurred vision

E. Frequent drooling - Correct answer A. Frequent syncope

C. Flat affect D. Blurred vision While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? A. Serum albumin B. Culture for sensitive organisms C. Serum blood glucose level

D. Creatinine level - Correct answer B. Culture for sensitive organisms

D. Skipped eating lunch - Correct answer C. Had a cold and ear infection for the

past two days A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? A. The impending signs of death should be documented B. The client's status should be conveyed to the chaplain C. The client's need for pain medication should be determined

D. The nurse manager should be updated on the client's status - Correct

answer C. The client's need for pain medication should be determined

Which self care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus? A. Self-injection techniques B. Blood glucose monitoring C. Diabetic diet meal planning

D. A realistic exercise plan - Correct answer B. Blood glucose monitoring

A client who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breasts are swollen, warm, and tender on palpation. Which instruction should the nurse provide? A. Apply ice to the breasts for comfort B. Wear a loose-fitting bra during the day to prevent nipple irritation C. Run warm water over breasts

D. Express small amounts of milk from the breasts to relieve pressure - Correct

answer A. Apply ice to the breasts for comfort

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply) A. Avoid range of motion exercises B. Use a residual limb shrinker C. Apply alcohol to the stump after bathing D. Inspect skin for redness

E. Wash the stump with soap and water - Correct answer B. Use a residual limb

shrinker D. Inspect skin for redness E. Wash the stump with soap and water A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting of milk products arrives to the clinic accompanied by the parents. Which type of testing should the nurse provide education to the toddler's family about?

A. Serum immunoglobulin E (IgE) B. Intradermal test C. Atopy patch test

D. Placebo-controlled food challenge - Correct answer A. Serum immunoglobulin

E (IgE) A client who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. In preparing the client for the procedure, which intervention has the highest priority? A. Allow client to gargle with warm salt water B. Administer a sedative to alleviate anxiety C. Instruct client to write down the questions

D. Deny client's request for a midnight snack - Correct answer C. Instruct client to

write down the questions The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse? A. Notify the nurse when the transfusion has finished, so further client assessment can be done B. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately D. Since a reaction did not occur, the priority is to maintain client comfort during the

transfusion - Correct answer B. Continue to measure the client's vital signs every

thirty minutes until the transfusion is complete The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care? A. Assess warmth of extremities B. Keep head of bed raised 45 degrees C. Monitor blood glucose level

D. Maintain strict intake and output - Correct answer D. Maintain strict intake and

output A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use? A. Ask the client to describe the pain B. Observe body language and movement C. Identify effective pain relief measures

D. Provide a numeric pain scale - Correct answer A. Ask the client to describe the

pain

D. Chronic cough and fatty stools - Correct answer B. Mucopurulent cough and

night sweats In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client become lethargic. Which assessment data should the nurse obtain next? A. Temperature B. Breath sounds C. Blood glucose

D. White blood cell count - Correct answer C. Blood glucose

A nurse receives report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reports that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first? A. Evaluate the skin turgor B. Assess for weakness or dizziness C. Change the perineal pad

D. Measure the urinary output - Correct answer B. Assess for weakness or

dizziness The father of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? A. Reassure the client that his child will be allowed to visit B. Provide the client written information about end-of-life care C. Obtain a detailed report from the nurse transferring the client

D. Mark the chart with client's request for no heroic measures - Correct answer C.

Obtain a detailed report from the nurse transferring the client While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement? A. Obtain sputum sample B. Document degree of edema C. Initiate hourly urine output measurement

D. Administer intravenous diuretics - Correct answer A. Obtain sputum sample

A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions?

(descending order) - Correct answer 1. Observe breathing patterns

  1. Assess blood pressure
  2. Measure body temperature
  3. Palpate for pedal edema A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation? A. Potassium 3.5 mEq/L B. Fingertips feel numb C. Sodium 135 mEq/L

D. Cervical spine stiffness - Correct answer B. Fingertips feel numb

An older client is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication? A. currently prescribed medications B. Client's healthcare power of attorney C. Increasing confusion of the client

D. Fall at home as reason for admission - Correct answer C. Increasing confusion

of the client The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs (2kg) in 24 hours and an elevated central venous pressure for a client with full thickness burns. Which intervention should the nurse implement? A. Auscultate for irregular heart rate B. Review arterial blood gases results C. Measure ankle circumference

D. Document abdominal girth - Correct answer A. Auscultate for irregular heart

rate The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply) A. Administer a dose of insulin per sliding scale for a client with Type 2 DM B. Start the second blood transfusion for a client 12 hours following a BKA C. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperatively D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy E. Obtain postoperative vital signs for a client one day following unilateral knee

arthroplasty - Correct answer A. Administer a dose of insulin per sliding scale for a

client with Type 2 DM

A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement? A. Obtain the client's 24-hour dietary recall B. Document mucosal membrane status C. Schedule a consult with a nutritionist

D. Initiate prescribed intravenous fluids - Correct answer D. Initiate prescribed

intravenous fluids A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teach the parents to report which sign of overdose? A. Bradycardia B. Tachypnea C. Hypertension

D. Coughing - Correct answer A. Bradycardia

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain? A. Upper body muscle strength B. Balance and posture C. Risk for disuse syndrome

D. Pressure sore risk - Correct answer A. Upper body muscle strength

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? A. A retraining program will need to be initiated when the child returns home. B. Diapering will be provided since hospitalization is stressful to preschoolers C. A potty chair should be brought from home so he can maintain his toileting skills D. Children usually resume their toileting behaviors when they leave the hospital -

Correct answer D. Children usually resume their toileting behaviors when they

leave the hospital The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) A. Report any client complaint of pain or discomfort B. Evaluate the client for sleep disturbances C. Assess the client for weakness and fatigue D. Weigh the client and report any weight gain E. Note and report the client's food and liquid intake during meals and snacks -

Correct answer A. Report any client complaint of pain or discomfort

D. Weigh the client and report any weight gain E. Note and report the client's food and liquid intake during meals and snacks

A young adult visits the client reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan? A. Consumes 10 or more drinks of alcohol every weekend B. Snacks on foods with very high salt content on a daily basis C. Exercises vigorously every evening right before going to bed

D. Recently became a vegetarian and eats a lot of high fiber foods - Correct

answer A. Consumes 10 or more drinks of alcohol every weekend

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? A. Auscultate for bowel sounds in all quadrants B. Ask the client about gastrointestinal pain C. Monitor the client's serum electrolyte levels

D. Measure the client's fluid intake and output - Correct answer B. Ask the client

about gastrointestinal pain When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding? A. The second stage of labor lasted 10 minutes B. She received butorphanol 2mg IVP during labor C. She is over 35 years of age

D. She is a gravida 6, para 5 - Correct answer D. She is a gravida 6, para 5

When assessing an IV site that is used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse? A. Client uses the arm cautiously B. Red streak tracking the vein C. A sluggish blood return

D. Spot of dried blood at insertion site - Correct answer B. Red streaks tracking

the vein An older adult male reporting abdominal pain is admitted to the hospital from a long- term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150mL of dark brown emesis. In what order should the

nurse implement these interventions? (Highest to lowest priority) - Correct

answer 1. Send emesis sample to the lab

  1. Elevate the head of the bed
  2. Complete focused assessment
  3. Offer PRN pain medication

Then nurse identifies several nursing problems for client who is immobile and who has been experiencing fecal incontinence and diarrhea for several days. The client's spouse is the primary caregiver. In planning care, which problem has the highest priority? A. Impaired bed mobility B. Caregiver role strain C. Fluid volume deficit

D. Bowel incontinence - Correct answer D. Bowel incontinence

The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? A. Teach coughing and deep breathing exercises B. Assess the client's oral cavity for ulcerations C. Request thick nectar liquids for the client

D. Monitor the client when using a straw for liquids - Correct answer A. Teach

coughing and deep breathing exercises An adult client is admitted to the emergency department after falling from the ladder. While waiting to have a computed tomography (CT) scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement? A. Review client's history for use of illicit drugs B. Explain the reason for using only non-narcotics C. Assess client's pupils for their reaction to light

D. Request that the CT scan be done immediately - Correct answer B. Explain the

reason for using only non-narcotics The nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD? A. Monitoring telemetry and cardiac rhythm B. Assisting client to cough and deep breath C. Administering narcotics for pain relief

D. Increasing the client's fluid intake - Correct answer C. Administering narcotics

for pain relief The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75mg IM every 4 weeks. The client begins developing a puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement? A. Monitor lying, sitting, and standing blood pressures B. Provide coaching in relaxation techniques C. Complete abnormal involuntary movement scale (AIMS)

D. Discontinue all medications immediately - Correct answer C. Complete

abnormal involuntary movement scale (AIMS)

Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect? A. Disrupted surfactant production B. Metabolic acidosis C. Aphasia and memory loss

D. Deep sleep or coma - Correct answer A. Disrupted surfactant production

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider? A. A change in the sleep-wake cycle B. Mild sedation C. Dizziness reported after initial dose

D. Somnambulism - Correct answer D. Somnambulism

The nurse instructs a client in use of a incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration? A. Auscultate the client's lungs for adventitious sounds B. Encourage the client to practice until successful C. Emphasize the need to inhale slowly into the spirometer

D. Remind the client to cough after using the spirometer - Correct answer D.

Remind the client to cough after using the spirometer A client tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The client states that it still is taking hours to fall asleep at night. Which action should the nurse implement? A. Advise the client that lifestyle changes often take several weeks to be effective B. Encourage the client to exercise everyday to eliminate bedtime wakefulness C. Ask the client for a description of the exercise schedule that is being followed D. Determine the amount of weight the client has lost since increasing activity -

Correct answer C. Ask the client for a description of the exercise schedule that is

being followed The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics? (Select all that apply) A. Uses common words with few syllables B. Printed using a 12-point type font C. Uses pictures to help illustrate complex ideas D. Contains a list with definitions of unfamiliar terms

E. Written at a twelfth-grade reading level - Correct answer A. Uses common

words with few syllables C. Uses pictures to help illustrate complex ideas

A client with urge incontinence was treated with onabotuilinumtoxinA injections and is now experiencing urinary retention. Which action should the nurse include in the client's plan of care? A. Provide a bedside commode for immediate use in the client's room B. Teach the client techniques for performing intermittent catheterization C. Explain the need to limit intake of oral fluids to reduce client discomfort

D. Remind the client to practice pelvic floor (Kegel) exercises regularly - Correct

answer D. Remind the client to practice pelvic floor (Kegel) exercises regularly

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? (Select all that apply) A. Location of the initial IV site B. Red blood cell count (RBC) C. Swollen lymph nodes in the groin D. White blood cell count (WBC)

E. Core body temperature - Correct answer C. Swollen lymph nodes in the groin

D. White blood cell count (WBC) E. Core body temperature The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement? A. Encourage family members to cook meals outdoors and bring the cooked food inside B. Assess the client's mucous membranes and report the findings to the healthcare provider C. Advise the client to replace cooked foods with a variety of different nutritional supplements D. Instruct the client to take an antiemetic before every meal to prevent excessive

vomiting - Correct answer A. Encourage family members to cook meals outdoors

and bring the cooked food inside The nurse is wearing personal protective equipment (PPE) while caring for a client. When exiting the room, which PPE should be removed first? A. Gloves B. Mask C. Eyewear

D. Gown - Correct answer A. Gloves

An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse's response should be based on what information? A. The client probably has an organic brain disease and will likely have Alzheimer's disease within a few years

B. The family needs a social worker to talk to them about how to handle their father when he becomes annoying C. The daughter is under stress and should be encouraged to think about happier times D. If the client was compulsive about food when he was younger, the aging process can

magnify this - Correct answer D. If the client was compulsive about food when he

was younger, the aging process can magnify this A client is receiving enoxaparin 30mg subcutaneously twice a day. In assessing for adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor? A. Glucose B. Calcium C. Platelet count

D. White blood cell count - Correct answer C. Platelet count

The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two-word phrases. Which assessment should the nurse administer? A. The modified checklist for autism in toddlers (M-CHAT) B. Psychology Systems Questionnaire (PHQ-2) C. Behavioral Style Questionnaire (BSQ)

D. The Ages and Stages Questionnaire (ASQ) - Correct answer A. The Modified

Checklist for Autism in Toddlers (M-CHAT) Prior to surgery, written consent must be obtained. Which is the nurse's legal responsibility with regard to obtaining written consent? A. Explain the surgical procedure to the client and ask the client to sign the consent form B. Ask the client or a family member to sign the surgical consent form C. Determine that the surgical consent form has been signed and is included in the client's record. D. Validate the client's understanding of the surgical procedure to be conducted -

Correct answer C. Determine that the surgical consent form has been signed and

is included in the client's record A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse? A. T3- uptake at 50% B. Glucose 150 mg/dL C. Total calcium 5.0 mg/dL

D. Thyroxine 12 mcg/dL - Correct answer C. Total calcium 5.0 mg/dL

A client in the third trimester of pregnancy reports that she fells some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an

An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? A. Prepare the client for an echocardiogram B. Document in the client's record C. Notify the healthcare provider

D. Limit the client's fluids - Correct answer B. Document in the client's record

A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his "right foot is aching". The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement? A. Encourage discussion of feelings about the loss of his limb B. Administer a prescription for gabapentin, a neuroleptic agent C. Tech the client how to wrap the stump with an elastic bandage

D. Offer to assist the client to a quieter location so he can relax - Correct

answer A. Encourage discussion of feelings about the loss of his limb

A combination multi-drug cocktail is being considered for an asymptomatic HIV-infected client with a CD4 cell count of 500. Which nursing assessment of the client is most crucial in determining whether therapy should be initiated? A. Willing to comply with complex drug schedules B. Maintains an adequate social support system C. Qualifies for a prescription assistance program

D. States various side effects of retroviral agents - Correct answer A. Willing to

comply with complex drug schedules The nurse is caring for a seated client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply) A. Loosen restrictive clothing B. Insert a bite block C. Ease the client to the floor D. Note the duration of the seizure

E. Restrain the client - Correct answer A. Loosen restrictive clothing

C. Ease the client to the floor D. Note the duration of the seizure On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain? A. Which family member has the client's suicide note B. What drugs the client used for the suicide attempt C. When the client last took drugs for bipolar disorder

D. Whether the client over attempted suicide in the past - Correct answer C.

When the client last took drugs for bipolar disorder The nurse has complete the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? A. A tuna fish sandwich with chips and ice cream B. A salad with three kinds of lettuce and fruit C. A peanut butter sandwich with soda and cookies

D. Vegetable soup, crackers, and milk - Correct answer A. A tuna fish sandwich

with chips and ice cream The nurse has received funding to design a health promotion project for African- American women who are at risk for developing breast cancer. Which resource is most important in designing this program? A. A listing of African-American women who live in the community B. Morbidity data for breast cancer in women of all races C. Participation of community leaders in planning the program

D. Technical assistance to produce a video on breast self-examination - Correct

answer C. Participation of community leaders in planning the program

A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? A. Suggest the nurse use a 20-gauge needle B. Instruct the nurse to remove the needle C. Direct the nurse to change the IV tubing

D. Prompt the nurse to apply povidone to the site - Correct answer A. Suggest the

nurse use a 20-gauge needle After reviewing the Braden Scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize skin care for which client? A. A poorly nourished client who requires liquid supplements B. An older adult who is unable to communicate elimination needs C. A woman with osteoporosis who is unable to bear weight

D. A older man whose sheets are damp each time he is turned - Correct

answer D. A older man whose sheets are damp each time he is turned

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. Which effect is the nurse likely to note as a result of this increase in glaucoma surgeries? A. Decreased prevalence of glaucoma in the population B. Increased incidence of glaucoma in the population C. Decreased morbidity in the elderly population