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HESI Practice

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HESI Practice

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1. 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.

D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.D!

Adolescence is a period of psychological, social, and maturational growth. There are subphases of adolescence. Middle adolescence occurs between the ages of 15 and 17. Prepubescence occurs 2 years before the onset of puberty. However, this patient has already achieved puberty and had her first menstrual flow. Postpubescence extends for 1 to 2 years after puberty. The patient has recently had her first menstrual flow and is at the point of puberty. Late adolescence occurs between the ages of 18 and 20.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.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.

2. A client who is to have brain surgery has a signed advance directive in the medical record. In what situation should this document be used?

a. Discharge planning is not covered by insurance.

b. Client cannot consent to his or her own surgery.

c. Postoperative complications occur that require additional treatment.

d. In case of the client's death, there will be directions about which client's belongings are to be given to family members.

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!

Adolescence is a period of psychological, social, and maturational growth. There are subphases of adolescence. Middle adolescence occurs between the ages of 15 and 17. Prepubescence occurs 2 years before the onset of puberty. However, this patient has already achieved puberty and had her first menstrual flow. Postpubescence extends for 1 to 2 years after puberty. The patient has recently had her first menstrual flow and is at the point of puberty. Late adolescence occurs between the ages of 18 and 20.D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.

3. A client using fentanyl (Duragesic) transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch?

a. Tell the family to remove and dispose of the patch.

b. Leave the patch in place for the mortician to remove.

c. Have the family return the patch to the pharmacy for disposal.

d. Remove and dispose of the patch in an appropriate receptacle.

B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.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!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.D!

Adolescence is a period of psychological, social, and maturational growth. There are subphases of adolescence. Middle adolescence occurs between the ages of 15 and 17. Prepubescence occurs 2 years before the onset of puberty. However, this patient has already achieved puberty and had her first menstrual flow. Postpubescence extends for 1 to 2 years after puberty. The patient has recently had her first menstrual flow and is at the point of puberty. Late adolescence occurs between the ages of 18 and 20.

4. The nurse is teaching hygiene practices to a 16-year-old patient who has recently had her first menstrual flow. Under which phase of development does the nurse classify the patient?

a. Prepubescence

b. Postpubescence

c. Late adolescence

d. Middle adolescence

D!

Adolescence is a period of psychological, social, and maturational growth. There are subphases of adolescence. Middle adolescence occurs between the ages of 15 and 17. Prepubescence occurs 2 years before the onset of puberty. However, this patient has already achieved puberty and had her first menstrual flow. Postpubescence extends for 1 to 2 years after puberty. The patient has recently had her first menstrual flow and is at the point of puberty. Late adolescence occurs between the ages of 18 and 20.D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.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.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.

5. A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? Select all that apply.

a. Take the aspirin with meals or a snack.

b. Make an appointment with a dentist if bleeding gums develop.

c. Do not chew enteric-coated tablets.

d. Switch to Tylenol (acetaminophen) if tinnitus occurs.

e. Report persistent abdominal pain.

D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.A, C, & E!

Acetylsalicylic acid (aspirin) is irritating to the stomach lining and can cause ulceration; the presence of food, fluid, or antacids decreases this response. Bleeding gums should be reported to the practitioner, not the dentist. Enteric-coated tablets must not be crushed or chewed. Acetaminophen does not contain the anti-inflammatory properties present in aspirin; tinnitus should be reported to the practitioner. Aspirin therapy may lead to GI bleeding, which may be manifested by abdominal pain; if present, the prescriber must be notified immediately.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.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.

6. A nurse is assessing a newly admitted client with a pressure ulcer indicated in the picture. What stage pressure ulcer should the nurse document on the admission history and physical?

a. Stage I

b. Stage II

c. Stage III

d. Stage IV

B!

A stage II pressure ulcer is a partial-thickness ulceration of epidermis or dermis; it presents as an abrasion, blister, or shallow crater, has a red/pink wound bed, has no tissue sloughing, and may have an intact/open serum filled blister. A stage I ulcer has tissue injury with a purple or maroon localized area of intact skin or blood-filled blister; the area may be firm, boggy, warmer, cooler, or painful in comparison with nearby tissue. A stage III pressure ulcer has full-thickness ulceration involving the epidermis, dermis, and subcutaneous tissue; sloughing may be present, it presents as a deep crater with or without undermining, and bone, tendon, or muscle are not exposed. A stage IV pressure ulcer involves full-thickness skin loss and damage to muscle, bone, or tendon; sloughing or eschar may be present on parts of the wound bed, and it often includes undermining and tunneling.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.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.

7. A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative?

a. 'Moderate amount of drainage.'

b. 'No change in drainage since yesterday.'

c. 'A 10-mm-diameter area of drainage at 1900 hours.'

d. 'Drainage is doubled in size since last dressing change.'

C!

Gradual weaning from prednisone (Meticorten) is necessary to prevent adrenal insufficiency or adrenal crisis. Prednisone depresses the immune system, thereby increasing susceptibility to infection. The drug usually suppresses growth. A moon face may occur, but it is not a critical, life-threatening side effect.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.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!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.

8. 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.'

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!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.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.

9. A nurse has just administered an immunization injection to a 2-month-old infant. What instructions should the nurse give the parent if the infant has a reaction?

a. Give aspirin for pain; if swelling at the injection site develops, call the health care provider.

b. Apply heat to the injection site for the first day after the injection; apply ice if the arm is inflamed.

c. Give acetaminophen for fever; call the health care provider if the child exhibits marked drowsiness or seizures.

d. Apply ice to the injection site if soreness develops; call the health care provider if the child comes down with a fever

C!

Fever is a common reaction to immunizations, and acetaminophen may be given to minimize discomfort. A central nervous system reaction is rare and requires notification of the health care provider. Aspirin should not be given to infants and children because it is linked to Reye syndrome. Infants do not tolerate the application of ice, which will increase discomfort. Fever is a common reaction to the immunizations; it is not necessary to notify the health care provider.D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.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.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.

10. A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report?

a. A statement that the nursing staff was not at fault because the client initiated the accident.

b. A listing of facts related to the incident as witnessed by the nurse.

c. The name of the nurse who was responsible for implementing the restraints.

d. The potential reasons why the restraints were not in place at the time of the fall.

D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.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.B!

The nurse filling out an incident or variance report needs to state only the objective facts surrounding the incident, no opinion or speculation. In an incident report fault or blame is subjective and should not be implied. It is not necessary to include names except for those of witnesses. Speculations or opinions as to the reason why the ordered restraints were not on the client are subjective and not appropriate to include in an incident or variance report.

11. A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? Select all that apply.

a. Age

b. Anorexia

c. Hemiplegia

d. History of diabetes

e. Urinary incontinence

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!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.B, C,D, & E!
Anorexia causes nutritional problems; nutrition is a category on the Braden Scale. Hemiplegia causes mobility problems; this impacts on the categories of mobility, activity, and friction on the Braden Scale. Urinary incontinence causes moisture, a category on the Braden Scale. Age is not used in the Braden Scale. Diseases are not used on the Braden Scale.

12. A father asks the nurse about the immunization schedule for his 15-month-old toddler, who is being treated for acute lymphoid leukemia. What vaccine is contraindicated for a child undergoing chemotherapy?

a. Hib (influenza)

b. HepB (hepatitis B)

c. MMR (measles, mumps, rubella)

d. DTaP (diphtheria, tetanus, acellular pertussis)

B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.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!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.C!

The MMR vaccine contains attenuated live virus and should not be administered to a child undergoing chemotherapy because of the compromise of the child's immune system. There are no contraindications to administering the Hib vaccine HepB vaccine, or DTaP vaccine to a child who is immunosuppressed.

13. The parents of a newborn discuss their infant's need for immunizations with the nurse. Which vaccine will not be administered until the child is at least 12 months of age?

a. Polio

b. Tetanus

c. Measles

d. Pertussis

B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.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!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.C!

The measles vaccine is not given before 12 months of age because the child still has passive natural immunity from the mother. Polio, tetanus, and pertussis vaccines are given during the first 6 months of life.

14. 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.'

D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.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.
TopicsB!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.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.

15. nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which behavior indicates understanding about the nursing team's responsibility in relation to pressure ulcers?

a. Inspecting the skin daily

b. Providing a rubber cushion on which to sit

c. Massaging body lotion over reddened areas

d. Applying a heating pad to bony prominences

D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.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.A!

Because the client is paralyzed and movement is compromised, daily inspection to determine the presence of reddened areas or lesions is necessary so that treatment can be initiated quickly. Providing a rubber cushion on which to sit may contribute to circumscribed pressure, which can lead to skin breakdown. Rubber promotes perspiration, which increases the risk of pressure ulcers. Massage of reddened areas may cause further damage and should be avoided. Because sensation may be compromised, a heating pad should not be used.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.

16. A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen?

a. Alcohol

b. Caffeine

c. Saw palmetto

d. St. John's wort

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.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.A!

Too much ingestion of alcohol can cause scarring and fibrosis of the liver. Eighty-five to 95% of acetaminophen is metabolized by the liver. Acetaminophen and alcohol are both hepatotoxic substances. Metabolites of acetaminophen along with alcohol can cause irreversible liver damage. Caffeine affects (stimulates) the cardiovascular system, not the liver. In addition, caffeine does not interact with acetaminophen. Saw palmetto is not associated with increased liver damage when taking acetaminophen. It often is taken for benign prostatic hypertrophy because of its antiinflammatory and antiproliferative properties in prostate tissue. St. John's wort is classified as an antidepressant and is not associated with increased liver damage when taking acetaminophen. However, it does decrease the effectiveness of acetaminophen.D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.

17. A nurse is caring for a client who was admitted with failure to thrive and severe muscle wasting due to malnutrition and immobility. When the nurse administers pills to the client, the client is not capable of holding the medicine cup. What technique should the nurse utilize to facilitate Physiological Aspects of Care?

a. Contact the client's health care provider. Ask to substitute a liquid form of medication for the pill form.

b. Remove one pill at a time from the medicine cup and place it into the client's mouth.

c. Crush the pills and administer with applesauce or ice cream.

d. Ask the client how many pills the client wants to take at one time. Drop them from the medication cup directly into the client's mouth.

D!

The client needs a physical assistance with Physiological Aspects of Care and therefore the nurse should help get the pills into the client's mouth while maintaining medical aseptic technique by using the medication cup and prevent aspiration by asking client how many pills the client would like to take at once. The client does not have difficulty swallowing and therefore substitution of pills by the liquid form of medication or crushing of pills is not necessary. Putting pills into the client's mouth by the hand is not safe for the nurse and violates medical asepsis; the choice does not mention that the nurse has gloves on.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!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.

18. An 18-month-old toddler who has received the appropriate immunizations on time is visiting the pediatric clinic for the next scheduled immunization. What vaccine should the nurse administer?

a. Second hepatitis B (Hep B) vaccine

b. Fifth inactivated polio vaccine (IPV)

c. First pneumococcal vaccine (PCV) and influenza vaccine (Hib)

d. Fourth diphtheria toxoid, tetanus toxoid, and acellular pertussis (DTaP) vaccine

B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.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!

The recommended age for the fourth dose of DTaP is 15 to 18 months. The recommended age for the second dose of Hep B is 4 weeks after the first dose, which is given immediately after birth. Four, not five, doses of IPV are recommended. The initial doses of PCV and Hib are given at 2 monthsD!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.

19. A client reports having a bad cold and chest pain that worsens when the client takes deep breaths. Where should the nurse place the stethoscope to determine the presence of a pleural friction rub? Choose the appropriate location marked on the image.

A.

B.

C.

D.

D!

Answer D is the lower-lateral chest, which is the area of greatest thoracic excursion. With visceral and parietal pleural inflammation (pleurisy), a low-pitched, coarse, grating sound is heard when the client breathes, particularly when approaching the height of inspiration. Bronchial breath sounds are heard over the trachea and at the nape of the neck on either side of the vertebrae. Bronchial sounds are loud, high pitched, and hollow, with a short inspiratory phase and long expiratory phase. Bronchovesicular breath sounds are heard on either side of the sternum or between the scapulae; bronchovesicular sounds have a moderate volume and medium pitch, with equal inspiratory and expiratory phases. C is the area where vesicular breath sounds are heard. Vesicular sounds are soft and low pitched, with a long inspiratory phase and a short expiratory phase; they are heard over most lung fields.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.

20. Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply.

a. Encouraging regular dental checkups

b. Facilitating smoking cessation programs

c. Administering influenza vaccines to older adults

d. Teaching the procedure for breast self-examination

e. Referring clients with a chronic illness to a support group

B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.A & D!

Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.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.

21. 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

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.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!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.

22. The parent of a 14-month-old toddler asks the nurse how to proceed with bowel training. What is the best response by the nurse?

a. Place the child on the toilet every 2 hours.

b. Start by having the child sit on a potty chair.

c. Avoid bowel training until the child is 2 years old.

d. Begin before the child's diet consists mainly of solid foods.

D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.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.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.B!

A potty chair is sized for a child and allows the child to display its contents with pride. A potty chair also allows the child to place the feet on the floor for an effective Valsalva maneuver to aid bowel evacuation. Sitting on a toilet seat can be frightening for a toddler. Timing of bowel training should coincide with the gastrocolic reflex. Bowel training should be started whenever the child shows readiness. A diet consisting mainly of solid foods will make stools bulkier and easier to control.

23. A client has a hiatal hernia. The client is 5 feet 3 inches tall and weighs 160 pounds. When the nurse discusses prevention of esophageal reflux, what should be included?

a. 'Increase your intake of fat with each meal.'

b. 'Lie down after eating to help your digestion.'

c. 'Reduce your caloric intake to foster weight reduction.'

d. 'Drink several glasses of fluid during each of your meals.'

B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.C!

Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. Lying down after eating increases the pressure against the diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal will increase the pressure; fluid should be discouraged with meals.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.

24. The nurse is teaching a class about nutrition to a group of adolescents. Taking into consideration the prevalence of overweight teenagers, what is the best recommendation the nurse can make?

a. Join a gym.

b. Drink fewer diet sodas.

c. Decrease fast food intake.

d. Take a multivitamin daily.

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.C!

Eating a variety of healthful foods instead of a fast-food diet that is high in fat and carbohydrates helps decrease excess weight and increase energy with which to engage in physical activities. Joining a gym is expensive and unnecessary. Physical activity can be achieved in the schoolyard or at home. A multivitamin will not promote weight loss. Vitamins and minerals are best obtained in a balanced diet. Diet soft drinks do not contribute to obesity.B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.D!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.

25. After surgery for a ruptured appendix, a 12-year-old child is receiving morphine for pain control by way of a patient-controlled analgesia (PCA) infusion. A bolus of morphine can be delivered every 6 minutes. A parent will be staying with the child during the immediate postoperative period. What statement indicates to the nurse that the instructions about the PCA pump have been understood?
1
'I'll make sure that she pushes the PCA button every 6 minutes.'
Correct2
'She needs to push the PCA button whenever she needs pain medication.'
3
'I'll have to wake her up on a regular basis so she can push the PCA button.'
4
'I'll press the PCA button every 6 minutes so she gets enough pain medication while she's sleeping.'

Morphine, an opioid analgesic, relieves pain; when control of pain is given to the child, anxiety and pain are usually diminished, resulting in a decreased need for the analgesic; only the child should press the PCA button. Having the child press the PCA button every 6 minutes is unnecessary. Although pain medication can be delivered as often as every 6 minutes, it should be used only if necessary. If the child is sleeping, the pain is under control; waking the child will interfere with rest. If the child is sleeping, the pain is under control; also, this will result in an unnecessary and excessive dosage of the opioid.

B!

Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.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!

The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.B!

Morphine, an opioid analgesic, relieves pain; when control of pain is given to the child, anxiety and pain are usually diminished, resulting in a decreased need for the analgesic; only the child should press the PCA button. Having the child press the PCA button every 6 minutes is unnecessary. Although pain medication can be delivered as often as every 6 minutes, it should be used only if necessary. If the child is sleeping, the pain is under control; waking the child will interfere with rest. If the child is sleeping, the pain is under control; also, this will result in an unnecessary and excessive dosage of the opioid.

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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