HESI 2016 Version 2

1. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough
of the solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter
numeric value only.) 200ml . 25 ml of full strength feeding mixed with 25ml of water provided
50ml of half strength. 25ml × 8 hours= 200m
2.An elderly male client is experiencing urinary incontinence. What is the best initial nursing
action? Apply an external condom catheter
3. 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?
Reschedule administration of the antibiotic until after he completes his prayers
4.UAP using a hand sanitzers that is alcohol for 2 minutes- tell that hand sanitizer use is less >
2min
5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled
procedure. The child weighs 44 pounds. How many mg of the medication should the nurse
administer. Answer: 800 Rationale: First, convert the child’s weight to kg: 44 pounds divided by
2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg
6.While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding
spurts rather than trickles from the vagina. The uterine fundus is firm and the client’s vital signs
are pulse 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68
mmHg. What action should the nurse take next? Compare current vital signs with previous vital
signs
7. A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood
imbedded in his eye. Which action should the school nurse take? Have the parent take the child
for emergency help
8. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech
bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse
identifies a nursing diagnosis of “Altered thought processes, secondary to” what condition?
Postpartum psychosis
9. 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? Regular aerobic exercise.
10. Psych/Alcohol/Tylenol overdose antidote – Give Mucomyst
11. Medical Surgical/Laxative abuses – Patient -taking Milk of Magnesium
12. Spiritual/Documentation- Native American – Allow pt’s family to stay in the room
13.Leadership- Interpreter informed consent – Pt should sign the consent
14. Geriatrics/Emergency Rib fractures fall – Pulmonary embolism
15. A client diagnosed with major depression is being allowed a weekend pass from the
psychiatric unit. Which instruction should the nurse provide to the client’s family? Involve the
client in usual at home activities
16. Upon assessment, the nurse discovers that a postpartum client has persistent red lochia.
Which of the following does this assessment finding suggest to the nurse? Coagulation disorders
17. The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is
drained. What action should the nurse complete first? Assess vital signs.

18. After administering a medication through a nasogastric tube connected to suction, what
action should the nurse take first? Clamp the tube
19. The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of
15,000. What should the nurse implement? Determine if Client B has two units of packed cells
available in the blood bank.
20. Triage question with a train wreck The psychiatric nurse is called to a train derailment that
was likely caused by a terrorist bomb. In triaging those in need of immediate care, what is the
priority ranking for these cases? (arrange these cases in order or priority with the top item
requiring the most immediate care and the bottom item requiring the least priority care) A mother
and father have just arrived on the . A crying child being held by another passenger. A woman
sitting on the ground with a blanket. A middle-aged man who is wandering around
21. (arrange in order) = middle age woman bleeding- woman w/ blanket- child crying- mother
and father. (Mine didn’t have a middle age woman bleeding, instead it had an old man wandering
and correct order is: wandering old man, woman w/blanket, man holding baby, and mother &
father)
22. The nurse in the emergency department is using the simple triage and rapid transport
(START) system to assess victims of a hurricane. Which statement correctly describes a yellow
disaster tag? A yellow disaster tag means critical injuries and require immediate intervention.
23. What makes a baby frontal bulge or rises= crying
24. Which of the following is a nursing intervention for a 3-year-old client who is going in for
sugery in 8 hours that has an order for fluid restriction? Do not allow the child to drink
fluids
25. The ear, where do u pull to give a ear drop= it a picture so look it up online (KNO CHILD &
ADULT) (pull the pinnae top side of ear; u can look at a picture to see exactly where pinnae is)
(Mine had a picture of ear and put it on the lobule of the pinnae it is the ear lobe). The eye
picture asked to find the macula or the fovea centralis (there are 2 prominent spots on the eye –
choose the DARK spot to the left not the spot where the light is)
26. Know your serum levels? K- 3.5-5.1, Na – 135-145, Ca 9-11, BUN – 10-20
27. When to use drug for motion sickness drug question – Take Zofran 4 hours before going
on trip via sea.
28. Pt with DM= she states that she has to eat lunch rite after the gets her insulin to prevent going
to hypoglycemia
29. Electrical burn pt= put him in a cardiac telemetry monitor
30. Which discharge instruction has the greatest priority for the mother of a 6-year-old who was
diagnosed with Type 1 diabetes mellitus one week ago? “Always carry a quick source of sugar
31. A nurse working on a mental health unit where a diagnosis of bulimia nervosa is being
admitted. Which of the following symptoms would the nurse most likely NOT expect to find
with this client? severe over-or under-weigh
32. 12yrs pt coming for surgery= have a tour of the OR with the a week before with the family
33. The charge nurse is developing the nursing guidelines for a coronary care unit. Which
references is likely to be the most useful in developing these guidelines? The Scope of Standards
of Practice from the American Nurses Association
34. Which assessment finding indicates a client's readiness to leave the nursing unit for a
Bronchoscopy? On-call sedation administered.
35. A nurse-manager is preparing an annual budget for the unit. Nursing salaries should be
included in which component of the budget? Operating budget
36. The nurse has not finished administering routine oral medication because on e client
experienced chest pain and another rectal bleeding. It is now dinner time and two clients must be
fed. The unlicensed assistive personnel (UAP) is filling water pitchers and the practical nurse
(PN) is charting vital signs. Which change in assignments is best for the team leader to make?
UAP feed the two clients, PN finish oral medications and RN monitor clients with chest pain and
rectal bleeding
37. What is manntiol drug used for? To promote diuresis in prevention and treatment of oliguric
phase of renal failure, ICP, IOP, edema in CHF.
38. The nurse is caring for a 42 year old male client who is excreting less sodium than he is
consuming. If this condition continues, what complication can the nurse expect this client to
exhibit? Edema
39. A 40-year-old client with type 1 diabetes developed chronic kidney (CKD) disease 6 months
ago. Because of secondary complications often associated with this illness the nurse plans to
carefully assess for signs of what condition? Anemia
40. A pt on a trachea/endotrach with gurgling sound= always pick suctioning
41. Know how the chest tube vac machine works – there is a picture of a chest tube vac machine.
Answer this q is very easy just mark the spot on the tube for the amount of 125 ml of drainage
42. Child w/ hemophila= have parent pad the corners of the furniture due to bleeding.
43. You are preparing a plan of care for a client who is a Jehovah's Witness.The client has been
told that surgery is necessary. With consideration to the client's religious preferences in
development of the plan of care, you would document what? The administration of blood
and blood products is forbidden
44. A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely
for what? Drug toxicity
45. A 68-year-old male has been admitted to the hospital with abdominal pain, anemia and
bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to
urinate and move his bowels. The nurse should help him onto the bedpan/with the urinal.
46. Nurse writes on the chart of Bob Miller that his nurse, Nurse Smith did not take great care of
Mr. Miller. Nurse Jones has committed which of the following? Libel.
47. A client is prescribed Zolpidem (Ambien). Which of the following side effects should be
monitored while the client is taking this medication? Daytime drowsiness
48. Translator is working with the nurse who is giving discharge instructions to a non-English
client. When the translator restates what the nurse is saying it appears that he is saying much
more than what the nurse said. What action should the nurse take? Ask the translator if there is a
reason for the lengthiness of the translation
49. Who is at risk for rib fracture - Elderly pt.
50. Splint- Chest compression or chest splint after surgery – they used it for comfort
51. Metabolic syndrome - high cholesterol & high BP (cardiac strip)
52. Know how to prevent SIDS death- Instruct parents to have a firm mattress and avoid laying
infant in prone position.
53. Hypertension Diet Teaching- presented with a list of menu choices, the best choice was
Baked pork chops, applesauce,etc
54. Teenager attempted suicide and during group session became upset and left group- Go to
client room and ask what happened.
55. Client has rapid speech, flight of ideas, 3hrs of sleep- client experiencing high levels
Depakote
56. New RN to Unit- best client to assign is client 4 days post MI
57. Incorrect Delegation - LVN/LPN to remove staples from abdominal wound
58. While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What
intervention should the nurse implement? Withdraw the nasogastric tube
59. One week after client received above the knee amputation, client experiences phantom pain
in left foot, what to do- Review causes and sensations of phantom pain
60. The nurse-manager of a perinatal units is notified that one client from the medical-surgical
unit needs to be transferred to make room for new admissions. Which client should the nurse
recommend for transfer to the antepartal unit? A 35-year-old with lupus erythematosus
61. Decerebrate Positioning – Extension of the upper and lower extremity.
62. Four clients arrive at the labor and delivery nurses’ station at the same time. Which pt should
the nurse assess first? A 38-week multigravida with biophysical profile score of 4 out of 8
63. Teenagers Teaching for Diabetic diet – Teach to look out for restaurant that have healthy
food.
64. Pyelonephritis symptoms - elevates temperature
65. Leg cast Assessment – Compartment syndrome
66. Diagnosis of breast cancer – Needle aspiration or biopsy.
67. Risk Osteoarthritis - seen in long distance runner since high school client
68. Client skin integrity for client with chronic venous insufficiency – around the ankle with little
pain.
69. IV Line - Flush line before and after compatible IV solution
70. Teaching - Carafate given before and after meal
71. Nurse given a change in drug orders via phone from physician for a client headed to
radiology, place in order what steps the nurse should take first to last? (Place in order) 1- read
order back 2-enter verbal prescription 3- administer prn meds 4- prepare client for x-ray
procedure
72. Heparin - Hematoma assessment
73. When the nurse auscultates the anterior chest just above the right nipple moderate, pitched
breath sounds are heard that are equal on inspiration and expiration. Which statement best
describes this finding? Bronchovesicular breath sounds that are normal in that location
74. Priority pt - Ruptured spleen life threatening
75. Magnesium – Alcohol pt (Magnesium 1.5 to 2.5)
76. Endotrach has slipped into right main bronchus of no breath sounds are heard (Audio/Visual)
Pleaurvac, know how to set vac at 850
77. Chron’s disease- decrease intestinal activity
78. Dialysis- educate client of the reality of condition
79. Acute Pancreatitis- withhold food and fluid intake
80. 39 to 48 Glucose- Notify healthcare provider of client’s status
81. Ankle brachial index- ensure that you provide meticulous foot care to client
82. Anterior Cruciate Ligament injury - crutches
83. (Select all that apply) Mantoux test-select all except 45-degree angle
84. Late decelerations- nurse should turn off the Pitocin infusion first
85. Crohn’s Disease – Which has lowest Na+- choose Horseradish (choices are ketchup, steak
sauce, pickle relish, horseradish)
86. Disseminated intravascular coagulation (DIC)- best test to diagnose, D-Dimer
87. Septic shock-best class of medicine to give are –Anti infectives
88. Adolescents and drug abuse at 13yrs old- mostly likely to use, Paint thinners
89. A female client who has been taking the corticosteroid methylprenisolone (Solu-Medrol) for
three weeks reports to the nurse that she has gained ten pounds since starting the medication, and
she wants to stop taking it. What is the best response by the nurse? The medication must be
disconnected gradually, tapering the dose each day.
90. In preparing assignments for the shift, which client is best for the charge nurse to assign to a
practical nurse? An elderly client with Alzheimer’s disease complicated by dysphagia.
91. A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood
imbedded in his eye. Which action should the school nurse take? Have the parent take the child
for emergency help
92. A nurse who is new to the pediatric unit is positioning a 6 month-old for an injection of
penicillin V (Pen V) in the dorsogluteal muscle. Which action should the nurse-manager who is
supervising this nurse take first? Instruct the nurse to select another injection site.
93. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse
provides home care instructions to the mother. Which statement by the child’s mother indicates
that she understands home care treatment to promote pulmonary function? “Cough suppressants
can be used four times a day.”
94. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech
bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse
identifies a nursing diagnosis of “Altered thought processes, secondary to” what condition?
Postpartum psychosis
95. The nurse is caring for a client who was admitted two hours ago with confusion, Kussmaul
respirations, and warm, flushed skin. The healthcare provider determines the client is in acute
renal failure (ARF). Which intervention is most important for the nurse to include in this clients
plan of care? Hourly neurological assessments.
96. The nurse observes a 2cm area of nonblanchable erythema on the sacrum of an immobile
client. What documentation of this finding is best for the nurse to enter into the client’s record?
Stage 1 pressure ulcer on sacrum.
97. A client diagnosed with major depression is being allowed a weekend pass from the
psychiatric unit. Which instruction should the nurse provide to the client’s family? Involve the
client in usual at home activities
98. A 14-year-old male client arrives at the emergency room in status epilepticus. He was
diagnosed with a seizure disorder in childhood. What is the most likely cause of his present
condition? Acute withdrawal from anticonvulsant medication.
99. A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After
delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What
intervention should the nurse implement first? Assist the client to sharply flex her thighs up
against the abdomen
100. The nurse is teaching a childbirth education class t prospective parents and describing
possible signs of labor. Class participants should be taught that which sign should be reported to
the healthcare provider immediately? Leaking of fluid from the vagina
101. During the first trimester of pregnancy, a client who was treated for genital herpes with
acyclovir (Zovirax) prior to this pregnancy tells the nurse that she is experiencing an episode of
genital herpes. Which nursing intervention has the highest priority? The highest priority in this
situation is to determine if the client has taken the drug Zoviarax, because Acyclovir has been
associated with birth defects.
102. The nurse is obtaining a medication history for a client with a new prescription for
paroxetine (Paxil). The client reports current use of the MAO inhibitor isocarboxazid (Marplan).
What intervention is most important for the nurse to implement? Notify the healthcare provider
that the client is currently taking Marplan.
103. After administering a medication through a nasogastric tube connected to suction, what
action should the nurse take first? Clamp the tube
104. What action should the nurse implement first when delegating nursing activities to an
unlicensed assistive personnel (UAP)? Evaluate the experience of the UAP.
105. The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of
15,000. What should the nurse implement? =Determine if Client B has two units of packed cells
available in the blood bank.
106. A 40-year-old client with type 1 diabetes developed chronic kidney (CKD) disease 6 months
ago. Because of secondary complications often associated with this illness the nurse plans to
carefully assess for signs of what condition? Anemia
107. A client diagnosed with acute epididymitis secondary to a sexually transmitted disease
receives a prescription for ceftriaxone (Rocephin). Prior to administering the prescription, which
question should the nurse ask the client? “Have you ever had an allergic reaction to any other
antibiotics?”
108. A client at 38 weeks gestation is in active labor, and a vaginal birth after Cesarean section
(VBAC) is planned. Vaginal exam indicates that the client is 6cm dilated, 90% effaced, and the
station 0 with intact membranes. As the client’s contraction become stronger, the fetal heart rate
decelerates during the contraction but returns to baseline. What action should be taken? Continue
to monitor the client’s labor progress.
109. An elderly client with limited mobility reports frequent episodes of nocturia. To reduce the
risk for urinary incontinence, what action should the nurse implement? Keep the call bell button
within the client’s reach.
110. Which diagnosis tests are most important for the nurse to monitor when providing care for a
client with a bowel movement? Serum electrolytes.
111. While assessing a client with wrist restraints the nurse first slides two fingers under the
restraints and then notes that the ties are secured to the side rail using a quick-release tie. What
action should the nurse implement? Reposition the restraints ties, securing them to the bed frame
112. After administering the first dose of newly prescribed medications to four clients within a
thirty minute time frame, the nurse evaluates each client for therapeutic responses or any adverse
reactions. Which medication should the nurse evaluate first? Hydromorphone (Dilaudid)
113. What is the most important symptom the nurse should monitor the client for while assisting
with the insertion of a subclavian central venous catheter? Shortness of breath.
114. A client admitted to the hospital is suspected of having meningitis. The nurse should plan to
prepare the client for which diagnostic test? Lumbar puncture
115. The nurse is performing an intake interview at a prenatal clinic. Which planned activities
described by the client who is at 6 weeks gestations will the nurse investigate first? Supervision
of the renovation of an old house the family just purchased due to teratogen defect.
116. The nurse notes that a postoperative adult client’s respiratory rate is 10 breaths/minute.
Which factor in the client’s history is the most likely explanation for this finding? The PCA
pump containing morphine sulfate was discontinued 15 minutes before vital signs were taken.
117. The nurse is assessing a client with hypothyroidism and knows that these clients are at risk
for myxedema coma. What symptoms indicate that the client is developing this condition?
Hypothermia, decreased cardiac output, and decreased respiratory functioning
118. While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What
intervention should the nurse implement? Withdraw the nasogastric tube
119. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother’s
vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus.
What action should the nurse take first? Perform fundal massage until firm
120. The nurse-manager of a perinatal units is notified that one client from the medical-surgical
unit needs to be transferred to make room for new admissions. Which client should the nurse
recommend for transfer to the antepartal unit? A 35-year-old with lupus erythematosus
121. Who is at risk for rib fracture - Elderly pt.
122. The nurse is assessing a client with hypothyroidism and knows that these clients are at risk
for myxedema coma. What symptoms indicate that the client is developing this condition?
Hypothermia, decreased cardiac output, and decreased respiratory functioning
123. A client is receiving a continuous infusion of normal saline at 125ml per hour. The nurse
prepares to change the primary IV tubing and hang a new bag of normal saline to maintain the
prescription. In which sequence should the nurse implement the procedure? (Arrange with first
on top and last on bottom.) Spike a new bag-open the clamp-close the clamp-place the pump-
attach the distal end-open all tubing clamps
124. A client who is wheelchair-bound demonstrates a positive Thomas test after admission to
the rehabilitation unit. The health care provider prescribes positioning the client prone for
30minutes three times each day to prevent further contractures. Based on this finding, what
change in the client’s plan of care should the nurse expect? There may be a delay in the
rehabilitation process.
125. While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What
intervention should the nurse implement? Withdraw the nasogastric tube
126. A client with a general anxiety disorder is pacing the hallway. The client tells the nurse,
“My heart is just racing and sometimes it feels like it’s fluttering. I’m feeling short of breath and
dizzy.” What action should the nurse implement first? Obtain the clients vital signs.
127. Translator is working with the nurse who is giving discharge instructions to a non-English
client. When the translator restates what the nurse is saying it appears that he is saying much
more than what the nurse said. What action should the nurse take? Ask the translator if there is a
reason for the lengthiness of the translation
128. An Elderly man is having trouble urinating and unsteady he uses a wheelchair to walk to the
bathroom what should the nurse implement? provide a raised toilet seat.
129. The nurse tests a client’s visual acuity and determines that the uncorrected vision is 20/100
in the right eye and 20/80 in the left eye. What does this finding indicate? Difficulty visualizing
objects at a distance also known as myopia.
130. Client has a Lithium Rx level of 0.54 (know Lithium ranges- Low, so the answer is to ask
client if they have been taking their medication everyday

131. (Select all that apply) Determining pain level for 3mo old infant- infant will clinch fists,
increase pulse, restlessness, increased respiratory effort
132. 5yr old burn victim has pot of hot liquid fall on him, what should nurse tell mother to do
first- nurse should tell mother to remove clothing and place in cool bath
133. The Nurse recognizes that the primary purpose of recommending a yearly digital rectal
examination (DRE) for all men over the age of 40 is to help detect the early stages of which type
of cancer? Prostate cancer.
134. A client with carpal tunnel syndrome is in the out-patient surgical unit after an endoscopic
carpal tunnel release. What instructions should the nurse provide the client regarding
postoperative care? After carpel tunnel release, measure to promote circulation, comfort, and to
prevent complications should include positioning the hand above the heart to reduce edema.
135. Which client should the nurse assist first? An inguinal hernia who has developed abdominal
distention and fever in the last 8 hours.
136. A client with a chest tube develops sepsis and dyspnea. Based on findings in the client’s
medical record, which prescription should the nurse implement first? (Click on each chart tab for
additional Information. Please be sure to scroll to the bottom right corner of each tab to view all
information contained in the clients medical record)
137. The nurse is teaching a client with COPD about health promotioin activities. What is the
most important advice the nurse should give this client? “If you have not already done so, quit
smoking”
138. A client at 38-weeks gestation complains of abdominal pain. The nurse notes that her
abdomen is rigid. What is the probable cause of these findings?
139. 39 to 48 Glucose- Notify healthcare provider of client’s status
140. Family members of a client who is in hospice care discuss with the nurse their fears that
their loved one’s death will be painful. Which intervention should the nurse implement?
Although the client may or may not experience pain as death approaches, the nurse should
provide teaching that pain control methods will be used, and are helpful in managing pain that
may occur.
141. Which nurse’s behavior is a breach of clients confidentiality according to the Health
Insurance Portable Accountability Act (HIPAA) regulations? Take home a daily report sheet with
the information of the team’s client.
142. A male client with cancer is admitted to the oncology unit and tells the nurse that he is in the
hospital for palliative care measures. The nurse notes that the client’s admission prescription
include radiation therapy. What action should the nurse implement? Consult with the client about
his expected goals for his hospitalization and current treatment plan
143. An Elderly man is having trouble urinating and unsteady he uses a wheelchair to walk to the
bathroom what should the nurse implement? provide a raised toilet seat.
144. The nurse completes the Leopold maneuvers for a primipara who is admitted in active labor
and determines that the fetus is in the right sacral anterior (RSA) position. On which quadrant
should the nurse place the external fetal heart transducer? (Click the chosen location. To change,
click on the new location.)
145. The nurse is caring for a 5 year-old child with Reye’s syndrome. What goal has the highest
priority in caring for this child? Reduce cerebral edema and lower intracranial pressure.
146. The nurse is preparing a discharge plan for an older client who was recently diagnosed with
Alzheimer’s disease. Which intervention should the nurse suggest to the spouse if the client
becomes uncooperative at home? Ensure a calm and predictable environment.
147. A mother brings her 15-month old son and 6 year-old daughter to the clinic for
immunizations. Both children are fretful and obviously have upper respiratory infections. The
mother tells the nurse that the younger child ran a fever of 100.2ºF following his last
immunization. What plan is best for the nurse to implement? Administer the boosters and instruct
the mother to call the clinic if either child’s temperature exceeds 101ºF.
148. Pregnancy Induced Hypertension high blood pressure, blurred vision, headache,
Proteinuria, Abdominal pain
149. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium
(Cs) loaded in a vaginal applicator. What action should the nurse implement? Wear a dosimeter
film badge when in the client’s room
150. A client who has localized eczematous eruptions on both hands is diagnosed as having
contact dermatitis. What instructions should the nurse include on the clients discharge teaching
plan? Take prescribed antihistamine near bedtime.
151. The community health nurse is attempting to address the issue of child abuse in a large
metropolitan area. A primary prevention program for child abuse might include which program?
High school child development and parenting classes.
152. Risk management: pt fell while using some equipment… charge nurse trying to find out
what happened- how? - hospital polices
153. A client has a history of chronic atrial fibrillation. Which instruction should the nurse
include in the teaching plan for this client? Be sure to take the prescribed daily aspirin.
154. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother’s
vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus.
What action should the nurse take first? Perform fundal massage until firm
155. It is most important for the nurse to use an IV pump and/or Buretrol, an in-line volume-
control device, when initiating IV therapy for a client following which surgical procedure?
Craniotomy.
156. Which strategy is most important for the nurse to use when assisting a client with
myasthenia gravis to devise a daily routine? Female with a head injury whose pupils are fixed
and dilated.
157. 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 min. Which drug is the transport team most likely to administer to the infant? Beractant
(SURVANTA) 100mg/kg per endotracheal tube.
158. A 60 year-old female client takes NPH insulin each morning. What would necessitate
holding this clients usual morning NPH insulin dose? The client is NPO for surgical debridement
of a leg ulcer at 11.00am.
159. Which finding should the nurse expect a client to exhibit who is newly diagnosed with
fibromyalgia? Disrupt in sleep patherns.
160. Chest tube disconnect ( Put the end of the tube in a sterile bottle fill with Normal saline and
connect back to patient)