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HESI Practice

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25 Questions

1. A nurse teaches the parents of a 4-year-old child who is to receive digoxin (Lanoxin) elixir at home about the basic principles regarding its administration. What statement indicates to the nurse that they need further teaching?

a. 'We'll brush his teeth after each dose.'

b. 'We won't mix the digoxin with fluids and foods.'

c. 'We shouldn't give an additional dose if he vomits.'

d. 'We should give the digoxin twice a day, at breakfast and dinner.'

D!

Tetanus immune globulin contains ready-made antibodies and confers short-term passive immunity. Passive immunity lasts a short time, not throughout life. Immune globulins confer passive artificial immunity, not long lasting active immunity. Immune globulins are antibodies; they do not stimulate the production of antibodies.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.

2. A nurse in the daycare center is teaching several aides about the play behavior of 2-year-old toddlers. What is this type of play called?

a. Group

b. Parallel

c. Dramatic

Cooperative

B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.D!

Tetanus immune globulin contains ready-made antibodies and confers short-term passive immunity. Passive immunity lasts a short time, not throughout life. Immune globulins confer passive artificial immunity, not long lasting active immunity. Immune globulins are antibodies; they do not stimulate the production of antibodies.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.

3. The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump?

a. Checking for the last bowel movement

b. Checking for residual stomach contents

c. Client's head of bed elevated at least 15 degrees

d. Last medication for nausea

D!

Tetanus immune globulin contains ready-made antibodies and confers short-term passive immunity. Passive immunity lasts a short time, not throughout life. Immune globulins confer passive artificial immunity, not long lasting active immunity. Immune globulins are antibodies; they do not stimulate the production of antibodies.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.

4. A construction worker sustains a puncture from a rusty nail. It is unknown when the worker had the last immunization for tetanus and the primary health care provider prescribes tetanus immune globulin. What protection does this type of immunization offer?

a. Lifelong passive immunity

b. Long lasting active protection

c. Stimulation of antibody production

d. Immediate passive short term immunity

5. A newly immigrated older Chinese adult is brought to a mental health clinic when family members become concerned that their parent is depressed. In an attempt to conduct a culturally competent assessment interview, the nurse asks certain questions. Select all that apply.

a. 'What brought you here for treatment today?'

b. 'What do you believe is the cause of your depression?'

c. 'Does religion have a role in your perception of health and wellness?'

d. 'Do you have insurance that includes coverage of mental health issues?'

e. 'Have you ever sought treatment for a mental health problem previously?'

D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.A, B, C, & E!

Determining the client's perception of the problem is an appropriate question that allows culturally factors to be included. Encouraging the client to discuss her problems will facilitate a clearer understanding of the factors involved. Religion often plays a significant role in a client's view of health, wellness, and recovery. Knowing whether a client has ever undergone treatment for a mental health problem reveals mental health history and how previous issues were addressed. Insurance coverage is not pertinent to the issue and is an inappropriate topic of questioning by the nurse.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.

6. A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient care analgesia (PCA) pump running with a basal rate of hydromorphone (Dilaudid). The nurse assesses the client's vital signs as BP 90/60 mm Hg, heart rate 96 beats/min, and respiratory rate of 10 breaths/min. What next action should the nurse take?

a. Document the findings and reassess in 2 hours.

b. Turn off the pump and give naloxone (Narcan) intravenous push med (IVP) per protocol.

c. Assess the client's pain level on a 10-point scale.

d. Call the rapid response team.

D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

A respiratory rate of 10 breaths/min is abnormal and needs to be treated immediately. Naloxone is an opioid antagonist and antidote and is used in PCA protocols for posoperative opioid-induced respiratory depression. According to protocol, PCA status also needs to be documented every 2 hours for the first day and then every 4 hours. Pain level also is a part of the PCA documentation protocol. The rapid response team might still need to be called, but naloxone must be given first.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.

7. A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What action should the nurse take when the infant begins to cough and gag?

a. Auscultating for breath sounds

b. Removing the tube, then reinserting it

c. Administering the tube feeding slowly

d. Observing the infant for circumoral cyanosis

D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

The infant's response indicates that the tube may be in the trachea rather than the stomach. The tube should be removed, reinserted, and verified for its placement before the feeding is started. Auscultating for breath sounds does not provide information about the placement of the tube. The tube should be removed immediately; it is unsafe to assess the infant for additional signs of respiratory distress. It is unsafe to administer the feeding until placement in the stomach has been confirmed.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.

8. A client who had a cerebrovascular accident (also known as a 'brain attack') becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program?
1
Using medication to induce elimination.
b. Adhering to a definite time for attempted evacuations.
3
Considering previous habits associated with defecation.
4
Timing of elimination to take advantage of the gastrocolic reflex.

B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.B!

Bowel training is a program for the development of a conditioned reflex that controls regular emptying of the bowel. The key to success is adherence to a strict time for evacuation based on the client's individual schedule. The indiscriminate use of laxatives can result in dependency. Although previous habits should be considered, the brain attack affects the responses of the client by altering motility, peristalsis, and sphincter control despite adherence to previous habits. The passage of food into the stomach does stimulate peristalsis, but it is only one factor that should be considered when planning a specific time for evacuation.

9. While receiving an adrenergic beta2 agonist drug for asthma, the client complains of palpitations, chest pain, and a throbbing headache. What is the most appropriate nursing action?

a. Withhold the drug until additional prescriptions are obtained.

b. Tell the client not to worry; these are expected side effects from the medicine.

c. Ask the client to relax, then give instructions to breathe slowly and deeply for several minutes.

d. Explain that the effects are temporary and will subside as the body becomes accustomed to the drug.

A!

These drugs cause increased heart contraction (positive inotropic effect) and increased heart rate (positive chronotropic effect). If toxic levels are reached, side effects occur and the drug should be withheld until the health care provider is notified. Telling the client not to worry; these are expected side effects from the medicine, is false reassurance and a false statement. Controlled breathing may be helpful in allaying a client's anxiety; however, the drug may be producing adverse effects and should be withheld.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.

10. A nurse in the pediatric clinic discusses the nutrition and feeding needs of an 18-month-old toddler with the child's parents. What information should the nurse include?

a. Growth rate increases, so more protein is needed per pound of body size.

b. Energy requirements become so high that more calories are needed to meet them.

c. Struggling for autonomy may involve refusal of food, but they will eat the amount they need.

d. Three meals a day should be offered, with no between-meal snacks, because they are finicky eaters.

C!

A toddler's increasing mobility and growing independence affects eating behaviors; slowed physical growth at this age requires relatively fewer calories. A toddler's growth rate and energy requirements decrease compared with the first year of life. Nutritious snacks between meals should be encouraged if the toddler is not eating adequate meals.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.

11. A health care provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker?

a. Weak upper arm strength and impaired stamina

b. Weight bearing as tolerated and unilateral paralysis

c. Partial weight bearing on the affected extremity and kyphosis

d. Strong upper arm strength and non-weight bearing on the affected extremity

B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.D!

A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.

12. Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include?

a. Encouraging daily physical exercise

b. Performing yearly physical examinations

c. Providing hypertension screening programs

d. Teaching a person with diabetes how to prevent complications

B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.A!

Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.

13. Which clinical indicators identified by the nurse support the probable presence of a fecal impaction in a client? Select all that apply.

a. Abdominal cramps

b. Fecal liquid seepage

c. Hyperactive bowel sounds

d. Bright red blood in the stool

e. Decreased number of bowel movements

A, B, & C!

Peristalsis increases in an attempt to evacuate the hardened feces; spasms of the intestine may occur. When the bowel is impacted with hardened feces, there often is seepage of liquid feces around the obstruction and thus uncontrolled diarrhea. Intestinal gas builds up behind the obstruction; peristaltic waves initiate movement of intestinal contents that cause gurgling sounds in the intestine (borborygmi). Bright red blood in the stool is indicative of lower gastrointestinal (GI) bleeding. There are often frequent liquid bowel movements in the presence of an impaction.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.

14. A hospitalized client is on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). Which statement by an unlicensed assistive personnel (UAP) indicates a need for further teaching?

a. 'I will wash my hands before entering and leaving the room.'

b. 'I will put on gloves and a gown before entering the room.'

c. 'I will leave a thermometer, blood pressure cuff, and stethoscope in the room for use for this client only.'

d. 'I will remove the gown, then the gloves, before washing my hands.'

D!

When removing personal protective equipment (PPE), the gloves should be removed before the gown, and then the hands should be washed. Contact precautions require the use of a gown and gloves. Hands should be washed before and after every client contact. Equipment should be dedicated for use only by the client in contact isolation.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.

15. After surgery a 5-year-old child experiences intense pain and an analgesic is prescribed. What should the nurse consider when administering the analgesic?

a. Even though children do not like medicines, analgesics will make them more comfortable.

b, Pain is not felt as strongly by children as by adults; therefore analgesics are not needed as frequently.

c. Children should rarely receive analgesics because they could cause addiction or respiratory depression.

d. Children do not need analgesics because they quickly return to playing or sleeping when they are distracted.

B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.A!

Children feel pain and should receive analgesics when needed. The idea that pain is not felt as strongly by children as it is by adults is a myth; it may be difficult for children to communicate pain. Not giving analgesics to children is a common but unsound belief; addiction and respiratory depression are rare. Some sources suggest that returning to play or sleep is a child's way of coping with unrelieved pain; however, it is no reason to withhold medication.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.

16. Since giving birth six months ago, a woman has breastfed her infant. The woman becomes hysterical after learning that her husband has been seriously injured in an automobile accident. Culturally this woman believes that emotional stress while breastfeeding can 'sour the milk,' and she indicates that she must wean her infant immediately. What should the nurse do?

a. Instruct the mother about formula feeding.

b. Explain to the mother that these beliefs are wrong.

c. Provide the mother with books indicating that the milk does not sour.

d. Encourage the mother to take an antianxiety drug while continuing breastfeeding.

D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.A!

The nurse should teach the mother how to formula feed, because cultural beliefs are deeply ingrained and it is unlikely at this time that the nurse will change the client's mind. Explaining to the mother that these beliefs are wrong is a judgmental response that does not take into consideration the client's beliefs or feelings. It is not therapeutic to contradict the client, especially when the alternative to breastfeeding will not harm the mother or infant. Providing the mother with books indicating that the milk does not sour is a judgmental response that does not recognize the client's beliefs or feelings. This is not therapeutic. Antianxiety medications are contraindicated in breastfeeding women.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.

17. A school nurse is planning a class on injury prevention for a group of high school students. What guidelines should the nurse include? Select all that apply.

a. Swim with a buddy.

Drink beer instead of wine.

c. Use well-traveled walkways.

d. Smoke only in designated areas.

e. Refuse to play 'chicken' with others.

A, C, & E!

Developmentally, adolescents have a drive for independence, an inclination for risk-taking, and a feeling of indestructibility. These traits increase the risk for injury. If one develops problems in the water, the buddy can secure help. Using well-traveled walkways reduces the risk for being alone and overcome by an individual who wishes to do harm. Refusing to play 'chicken' helps the student avoid him- or herself in dangerous situations from which the student cannot retreat. Beer is alcohol, and its intake, and that of all types of alcohol, should be discouraged; when one is under the influence of alcohol, reaction time and judgment decrease and the risk for injury increases. Smoking should be discouraged to decrease the risk for respiratory disease.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.

18. Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply.

a. Prayer

b. Hypnosis

c. Medication

d. Aromatherapy

e. Guided

D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.A, B, D, & E!

Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

19. On the third postpartum day a woman who is breastfeeding calls the nurse at the clinic and asks why her breasts are tight and swollen. What should the nurse consider before explaining why her breasts are engorged?

a. There is an overabundance of milk.

b. Breastfeeding is probably ineffective.

c. The breasts have been inadequately supported.

d. The lymphatic system in the breasts is congested.

B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.D!

An exaggeration of venous and lymphatic circulation caused by prolactin occurs before lactation. Effective breastfeeding does not prevent engorgement; a lag between the production of milk and the efficiency of the ejection reflex often causes engorgement. Engorgement occurs before lactation or milk production. Inadequately support of the breasts does not cause engorgement, but support may relieve some of the discomfort.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.

20. A nurse is teaching a client and family about the characteristics of dementia of the Alzheimer type. What physiological characteristic should the nurse include?

a. Periodic exacerbations

b. Aggressive acting-out behavior

c. Hypoxia of selected areas of brain tissue

d. Areas of brain destruction called senile plaques

B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.D!

When an older person's brain atrophies, some unusual deposits of iron are scattered on nerve cells. Throughout the brain, areas of deeply staining amyloid, called senile plaques, can be found; these plaques represent the end stage of destruction of brain tissue. Periodic exacerbations are associated with chronic deterioration, not with remissions and exacerbations. Aggressive acting-out behavior may or may not be part of the disorder. Hypoxia of selected areas of brain tissue is typical of vascular dementia, not dementia of the Alzheimer type.

21. A young client who has become a mother for the first time is showing signs of being anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. What kind of prevention does this activity reflect?
a. Primary prevention

b.Tertiary prevention

c. Secondary prevention

d. Therapeutic prevention

D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.A!

Primary prevention is directed toward health promotion and prevention of problems. Tertiary prevention is focused on rehabilitation and the reduction of residual effects of illness. Secondary prevention is related to early detection and treatment of problems. There is no category of prevention called therapeutic prevention.

22. The nurse is teaching crutch-walking to a 12-year-old child. What does the child do that indicates the need for more teaching?

a. Takes short steps of equal length

b. Looks forward to maintain balance

c. Looks down when placing the crutches

d.Assumes an erect posture when walking

C!

The child should maintain an erect walking posture, without looking down, to ensure equilibrium and avoid losing balance. Taking short steps is the correct technique for safe ambulation while crutch-walking. Looking forward is the correct technique for safe ambulation while crutch-walking; it keeps the body's center of gravity over the hips. Maintaining an erect posture is the correct technique for safe ambulation during crutch-walking; it keeps the body's center of gravity over the hipsB!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.

23. A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next?

a. Encourage rest.

b. Obtain vital signs.

c. Administer the prescribed analgesic.

d. Document the client's pain response.

B!

Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and physiologic rest. Before administration of an analgesic, the nurse must check the health care provider's prescription, the time of the last administration, and the client's vital signs. A complete assessment including vital signs should be done before documenting.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.

24. The nurse is teaching a mother about the developmental behaviors of a 7-month-old infant. Which statement by the mother indicates effective learning? Select all that apply.

a. 'I should start oral hygiene in my child.'

b. 'I should not change my child's diet.'

c. 'I should call my child by her name.'

d. 'I should not leave the child with an unfamiliar relative.'

e. 'I should encourage my child to produce n, k, g, p, and b sounds.'

A, C, & D!

The upper central teeth begin to erupt in a 7-month-old infant; therefore, the mother can buy a toothbrush with soft bristles to maintain oral hygiene. A 7-month-old infant can remember and respond to his or her own name. A 7-month-old infant often has a fear of the strangers, so the mother should not leave the infant with new people. A 7-month-old infant has taste preferences, so the mother can expose the child to different foods. A 7-month-old infant is able to say words such as dada, baba, kaka, etc. Therefore, the parents should encourage the infant to produce these words, not specific sounds like n, k, g, p, and b.
TopicsD!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.

25. A female client who has recurrent urinary tract infections (UTIs) is inquiring about the prevention of future UTIs. What information should the nurse include when teaching the client? Select all that apply.

a. Avoid fluid intake after 6 pm

b. Drink 8 to 10 glasses of water each day

c. Urinate immediately after sexual intercourse

d. Increase the daily intake of carbonated beverages

e. Clean the perineal area with an astringent soap twice a day

B!

Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.B!

Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.B & C!

Drinking 8 to 10 glasses of water spaced throughout the day flushes the urinary tract and minimizes urinary stasis. Urination flushes the urethra and urinary meatus, limiting the presence of microorganisms. Limiting fluid intake contributes to stasis of urine. Carbonated and caffeinated beverages irritate the bladder and should be avoided. Cleaning the perineum with harsh soaps is irritating to the skin and mucous membranes, and can contribute to the development of UTIs in susceptible women.

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25 Questions

❤ If you liked Fatskills, consider supporting us by checking out The Life Manuals You Never Got.

About | Explore | User Guide | Topics | Subjects | Doubt Solver | Career Aptitude Test | Answers | Free Tools | What Should We Know? Privacy | Terms |

Without work one finishes nothing. - Ralph Waldo Emerson© 2026 Fatskills.com

All trademarks, logos and brand names are the property of their respective owners. All company, product and service names used in this website are for identification purposes only. Use of these names, trademarks and brands does not imply endorsement.

About | Explore | User Guide | Topics | Subjects | Doubt Solver | Career Aptitude Test | Answers | Free Tools | What Should We Know?
Privacy | Terms |

Without work one finishes nothing. - Ralph Waldo Emerson
© 2026 Fatskills.com