1 NGN NURSING MED SURG HESI EXIT EXAM LATEST
2024 TEST BANK WITH RATIONALES COMPLETE
RATED A+
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have
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been applying triple antibiotic ointment for two days, but there has been no
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improvement." What instruction should the nurse provide?
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(ANS- Stop using the ointment and encourage complete drying of the feet and
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wearing clean socks.
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A 26-year-old female client is admitted to the hospital for treatment of a simple goiter,
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and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to
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the nurse that the prescribed dosage is too high for this client? The client experiences
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Bradycardia and constipation f f
Lethargy and lack of appetite
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Muscle cramping and dry, flushed skin
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Palpitations and shortness of breath
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(ANS- Palpitations and shortness of breath
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A client with a history of heart failure presents to the clinic with nausea, vomiting,
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yellow vision and palpitations. Which finding is most important for the nurse to
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assess to the client?
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(ANS- Obtain a list of medications taken for cardiac history
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The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in
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250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to
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deliver how many ml/hour? (Enter numeric value only.)
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(ANS- 75 f
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000
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,2 mcg x 250 ml = 3/1 x 25 = 75 ml/hour
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The pathophysiological mechanisms that are responsible for ascites related to liver
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failure? (Select all that apply)
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(ANS- Fluid shifts from intravascular to interstitial area due to decreased serum
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protein
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Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
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Increased circulating aldosterone levels that increase sodium and water retention
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The nurse is auscultating a client's heart sounds. Which description should the
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nurse use to document this sound? (Please listen to the audio first to select the
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option that applies)
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(ANS- Murmur f
Rationale: A murmur is auscultated as a swishing sound that is associated with the
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blood turbulence created by the heart or valvular defect.
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The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for
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an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to
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provide a concentration of 100 mg/ml. How many ml should the nurse administered
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for each dose? (Enter numeric value only. If rounding is required, round to the
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nearest tenth)
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(ANS- 0.4 f
ationale: 35mg/100mg x 1 = 0.35 = 0.4 ml f f f f f f f f
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six
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hours for four days. What assessment is most important for the nurse to complete?
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Auscultate the client's bowel sounds f f f f
Observe for edema around the ankles
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Measure the client's capillary glucose level
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Count the apical and radial pulses simultaneously
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(ANS- Auscultate the client's bowel sounds
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,3 Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and
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frequently causes constipation, so it is most important to Auscultate the client's
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bowel sounds
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A female client is admitted with end stage pulmonary disease is alert, oriented, and
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complaining of shortness of breath. The client tells the nurse that she wants "no
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heroic measures" taken if she stops breathing, and she asks the nurse to document
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this in her medical record. What action should the nurse implement?
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(ANS- Ask the client to discuss "do not resuscitate" with her healthcare provider
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A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and
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has developed diarrhea. The client has a new prescription to change the feeding to
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half strength. What intervention should the nurse implement?
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(ANS- Add equal amounts of water and feeding to a feeding bag and infuse at
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50ml/hour
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A female client reports that her hair is becoming coarse and breaking off, that the
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outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which
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follow-up question is best for the nurse to ask?
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(ANS- Have you noticed any changes in your fingernails?
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Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
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Following discharge teaching, a male client with duodenal ulcer tells the nurse the he
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will drink plenty of dairy products, such as milk, to help coat and protect his ulcer.
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What is the best follow-up action by the nurse?
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(ANS- Review with the client the need to avoid foods that are rich in milk and cream
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A male client with hypertension, who received new antihypertensive prescriptions at
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his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP).
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His BP is 158/106 and he admits that he has not been taking the prescribed
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medication because the drugs make him "feel bad". In explaining the need for
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hypertension control, the nurse should stress that an elevated BP places the client at
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risk for which pathophysiological condition?
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(ANS- Stroke secondary to hemorrhagef f f f
, 4 The nurse observes unlicensed assistive personnel (UAP) positioning a newly
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admitted client who has a seizure disorder. The client is supine and the UAP is
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placing soft pillows along the side rails. What action should the nurse implement?
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(ANS- Instruct the UAP to obtain soft blankets to secure to the side rails instead of
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pillows.
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An adolescent with major depressive disorder has been taking duloxetine
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(Cymbalta) for the past 12 days. Which assessment finding requires immediate
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follow-up?
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(ANS- Describes life without purpose
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A 60-year-old female client with a positive family history of ovarian cancer has
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developed an abdominal mass and is being evaluated for possible ovarian cancer. Her
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Papanicolau (Pap) smear results are negative. What information should the nurse
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include in the client's teaching plan?
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(ANS- Further evaluation involving surgery may be needed
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A client who recently underwear a tracheostomy is being prepared for discharge to
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home. Which instructions is most important for the nurse to include in the discharge
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plan?
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(ANS- Teach tracheal suctioning techniques
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In assessing an adult client with a partial rebreather mask, the nurse notes that the
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oxygen reservoir bag does not deflate completely during inspiration and the client's
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respiratory rate is 14 breaths / minute. What action should the nurse implement?
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(ANS- Document the assessment data
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Rationale: reservoir bag should not deflate completely during inspiration and the
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client's respiratory rate is within normal limits.
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During shift report, the central electrocardiogram (EKG) monitoring systemalarms.
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Which client alarm should the nurse investigate firs?
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(ANS- Respiratory apnea of 30 seconds
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