HESI EXIT RN EXAM V3 2022 (Q & A) verified answers-2023

HESI EXIT RN 2022

V3 160 Questions &

Answers

HESI EXIT

RN

2022 V3

160

Questions

1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a

nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One

hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the

client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to

reporting the finding to the surgeon. Which action should the nurse implement first?

a. Measure and document the client’s urinary output.

b. Request the client’s reserved unit if packed red blood cells.

c. Prepare the placement of a central venous catheter.

d. Increase the infusion rate of Lactated Ringer’s solution.

2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right

pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to

the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the

- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red

blood is measured in the collection chamber. Which intervention should the nurse implement?

a. Add sterile water to the suction control chamber.

b. Give blood from the collection chamber as autotransfusion

c. Manipulate blood in tubing to drain into chamber.

d. Increase wall suction to eliminate fluctuation in water seal.

3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100

mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is

manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air

of 89%. Which action should the nurse take first?

a. Elevate the foot of the bed.

b. Restrict the client’s fluid.

c. Begin supplemental oxygen.

d. Prepare the client for hemodialysis.

4. A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation.

Based on the client’s admitting diagnosis, which findings require immediate action by the nurse?

(Select all that apply)

a. Headache and tremors

b. Irregular heart rate

c. Skin hyperpigmentation

d. Postural hypotension

e. Pallor and diaphoresis

5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding

is the best indicator of hydration that the nurse should report to the healthcare provider?

a. Urine specific gravity is 1.040

b. Systolic blood pressure decreases 10 points when standing.

c. The client denies being thirsty.

d. Skin tenting occurs when the client’s forearm is pinched.

6. After an inservice about electronic health record (EHR) security and safeguarding client

information, the nurse observes a colleague going home with printed copies of client

information in a uniform pocket. Which action should the nurse take?

a. File a detailed incident report with the specific hiring facility.

b. Warn the colleague that their actions are unprofessional.

c. Comment anonymously about the action of a staff discussion board.

d. Communicate the colleague’s actions to the unit charge nurse.

7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease

implemented in a rural health clinic. Which outcome indicate the program is effective?

a. At-risk clients received an increased number of routine health screenings.

b. Clients reported having new confidence in making healthy food choices.

c. Clients who incurred disease complications promptly received rehabilitation.

d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.

8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses

oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is

having increased shortness of breath with respirations at 23 breaths/minute. Which action

should the nurse implement first?

a. Determine if the client is experiencing any anxiety.

b. Auscultate the client’s bilateral lung sounds and oxygen saturation.

c. Notify the healthcare provider about the client’s distress.

d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.

9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an

immediate investigation by the nurse?

a. “When I get out of bed quickly, I feel a little dizzy.”

b. “The dressing over my incision feels like it is too tight.”

c. “I’m most comfortable when the head of the bed is raised.”

d. “This IV infusion makes me urinate more often than usual.”

10. An older adult male who is in his early 70’s is admitted to the emergency department because of

a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing

for endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the

nurse to stop the procedure and provide the nurse a copy of the client’s living will. Which action

should the nurse take?

a. Facilitate a family meeting with the palliative care team.

b. Notify the healthcare provider of the client’s wishes.

c. Place a certified copy of the living will in the client’s record.

d. Alert the nursing staff of the client’s don’t resuscitate status.

11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose

prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the

client is so obese that the UAP feels unable to safely assist the client in transferring from the bed

to the bedside commode. How should the nurse respond?

a. Determine the client’s level of mobility and need for assistance.

b. Instruct the UAP that all clients deserve equal care.

c. Advice the client to maintain bedrest so that safety can be ensured.

d. Assign another UAP to care for the client.

12. A nurse determines that more than 25% of the students at a middle school are overweight. The

nurse presents the information at the parent-teacher meeting. What action is most important

for the nurse to include in the meeting?

a. Provide information on ways to increase activity for the family.

b. Have several teachers talk about health risks associated with obesity.

c. Distribute a shopping list of suggested healthy snack items.

d. Determine the parents’ degree of concern about their children’s weight.

13. After several months of chronic fatigue, morning stiffness, and join pain, a young adult is

diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which

education should the nurse provide the client with regard to taking prednisone?

a. Take prednisone doses before meals on an empty stomach.

b. Wear sunglasses when exposed to bright sunlight.

c. If sequential doses are missed, notify the healthcare provider.

d. Schedule a monthly laboratory visit for a complete blood count.

14. The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the

nurse’s immediate attention?

a. A 16-year-old client diagnosed with major depression who refuses to participate in group.

b. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.

c. An 18-year-old client with antisocial behavior who is being yelled at by other clients

d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby..

15. The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

a. Positive Epstein-Barr, and malaise.

b. Ear pain and fever.

c. Elevated WBC and sedimentation rate.

d. Increased BUN and serum creatinine.

16. A client arrives for an annual physical exam and complains of having calf pain. The client’s health

history reveals peripheral atrial disease. Which question should the nurse ask the client about

expected finding related to chronic arterial symptoms?

a. Were your legs ever suddenly swollen, red, warm, and painful?

b. Does the calf pain occur when walking short distances?

c. Did you receive treatment for weeping ulcers on lower legs?

d. Have you experienced ankle edema and varicose veins?

17. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty.

Which client report is most important for them to explore further prior to the start of the

procedure?

a. Drank a glass of water in the past 2 hours.

b. Reports left chest wall pain prior to admission.

c. Verbalize a fear of being in a confined space.

d. Experience facial swelling after eating crab.

18. The nurse is assessing a 4-year-old child with eczema. The child’s skin is dry and scaly, and the

mother reports that the child frequently scratches the lesions on the skin to the point of causing

bleeding. Which guideline is indicated for care of this child?

a. Keep the nails trimmed short.

b. Apply baby lotion to the skin twice daily.

c. Bathe the child daily with bath oil.

d. Allow the child to wear only 100% cotton clothing.

19. A new mother on the postpartum unit runs out of the room screaming that her newborn infant’s

crib is empty and the baby is missing. What action should the nurse take first?

a. Determine if the newborn is in the nursery.

b. Activate the lockdown procedure.

c. Ask the mother if any visitors were expected to arrive.

d. Match ID bands of all infants and mothers on the unit.

20. While providing a health history, a female client tells the clinic nurse that she frequently thinks

about hurting herself. Which question is most important for the nurse to ask?

a. “Do you often have feeling of sadness?”

b. “Are you having problems concentrating?”

c. “Have you though about taking your life?”

d. “What problems are you facing right now?”

21. A college student brings a dorm roommate to the campus clinic because the roommate has

been talking to someone who is not present. The client tells the nurse that the voices are saying,

“kill, kill.” What question should the nurse ask the client next?

a. “When did these voices begin?”

b. “Have you taken any hallucinogens?”

c. “Are you planning to obey the voices?”

d. “Do you believe the voices are real?”

22. The nurse is developing a plan of care for a client who reports tingling of the feet and who is

newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in

the plan of care for this client?

a. The client will express acceptance of their newly diagnosed health status.

b. The nurse will encourage the client to walk thirty minutes everyday.

c. The client’s blood pressure readings will be less than 160/90 mmHg.

d. The client’s skin on the lower legs will be intact at the next clinical visit.

23. When conducting diet teaching for a client who was diagnosed with hypertension, which food

should the nurse encourage the client to eat? (select all that apply.)

a. . Fruits without sauce

b. Canned soup.

c. Fresh or frozen vegetables without sauce.

d. Cottage cheese.

e. Pickled olives.

24. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to

the nurse that the client is experiencing a therapeutic response to the phenytoin?

a. Increased time of ambulation between periods of rest.

b. Decrease in intracranial pressure and cerebral edema.

c. Absence of seizure activity for the duration of treatment.

d. Normal electroencephalogram after drug administration.

25. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to

discharge. Which behaviors indicate the client understands how to maintain balance safely?

(Select all that apply)

c. Widens stance while working near the sink.

d. Bends from the waist to pick trash off the floor.

e. Leansforward to pull a pan from a high shelf.

26. An older client is admitted to the hospital because of recurring transient ischemic attacks.

Neurological serial assessments for the past 24 hours were within normal limits. One day after

admission, the client suddenly becomes confused and combative indicating impaired mental

status (IMS). What intervention should the nurse implement first?

a. Document neurologic changes.

b. Reduce environmental stimuli.

c. Administer prescribed neuroleptic.

d. Review medications for interactions.

a. Brings a heavy can close to body before lifting.

b. Locks knees while preparing food on the counter.

27. The charge nurse in an extended care facility is organizing unit activities for the day. Which

action may be safely delegated to the practical nurse (PN)?

a. Measure the client’s body weight each morning.

b. Establish blood pressure parameters for client monitoring

c. Evaluate a staff member providing wound care.

d. Evaluate client teaching through return demonstration.

28. During shift report, the charge nurse receives notice of several problems. Which problem should

the nurse address first?

a. The census report has not been completed.

b. A client’s wife has asked to speak with the charge nurse.

c. One staff member has not reported to work.

d. A bucket of water was spilled in the hallway.

29. An older adult client with chronic emphysema is admitted to the emergency room from home

with acute onset of weakness, palpitations, and vomiting. Which information is most important

for the nurse to obtain during the initial interview?

a. History of smoking over the past 6 months.

b. Sleep patterns during the previous few week.

c. Activity level prior to onset of symptoms.

d. Recent compliance with prescribed medications.

30. The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is

weak and begins coughing while attempting to drink through a straw. Which intervention should

the nurse implement?

a. Assess the client’s oral cavity for ulcerations.

b. Monitor the client when using a straw for liquids.

c. Teach coughing and deep breathing exercises.

d. Request thick nectar liquids for the client.

31. A male client with right-sided weakness calls for assistance with ambulating to the bathroom.

What action should the nurse implement?

a. Bring a bedside commode to the client.

b. Stand on the client’s right side as he walks.

c. Walk directly behind the client to prevent a fall.

d. Give the client a cane to hold in his right hand.

32. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia.

The nurse notes that in the evening this client often becomes restless, confused, and agitated.

Which intervention is most important for the nurse to implement?

a. Ask family members to remain with the client in the evening from 1700 to 2100 p.m.

b. Ensure that the client is assigned to a room close to the nurses’ station.

c. Postpone administration of nighttime medications until after 2300 p.m.

d. Administer a prescribed PRN benzodiazepine at the onset of a confused state.

33. The nurse is caring for a client who is having a sickle cell crisis. What intervention should the

nurse include in this client’s plan of care?

a. Ensure adequate IV and oral fluid intake.

b. Provide ice packs to major joint areas.

c. Space analgesics to prevent addiction to narcotics.

d. Re-enforce the importance of nutritional balance.

34. The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of

preeclampsia and should be reported to the healthcare provider? (select all that apply.)

a. Blurred vision

b. Headache.

c. Lack of appetite.

d. Urinary frequency.

e. Chills and fever.

f. Swollen hands.

35. A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which

action should the charge nurse implement?

a. Suggest the nurse use a 20-gauge needle.

b. Direct the nurse to change the IV tubing.

c. Instruct the nurse to remove the needle.

d. Prompt the nurse to apply povidone to the site.

36. A client with syndrome of inappropriate antidiuretic hormone secretion (SIDH) is admitted with

hyponatremia. Which intervention is most important for the nurse to include in the plan of care

to protect the client from injury?

a. Initiate seizure precautions.

b. Assess neurological status every 8 hours.

c. Limit oral water intake.

d. Administer a hypertonic IV fluids as prescribed.

37. The nurse is assigned to provide care for a client who is scheduled for a laparoscopic

cholecystectomy in two hours, at 0900, what nursing action is most important?

a. Confirm that the client has been NPO since midnight.

b. Review postoperative instructions with the client.

c. Offer to assist the client to the restroom to void.

d. Determine when the client last had pain medication.

38. The nurse is conducing a visual screening of a group of older adults. Which finding should the

nurse report to the healthcare provider immediately?

a. Gradual onset of continuous eye pain and blurred vision.

b. Recent change in the ability to read and drive after dark.

c. Gray-white circle around the iris of both eyes.

d. Cloudy opacity of the crystalline lens.

39. A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the

nurse that he is having difficulty adhering to his meal plan when he is with his friends. What

nursing intervention is best for the nurse to implement?

a. Recommend he avoid fast food restaurants until he is familiar with his prescribed diet.

b. Advise him to take his own food with him when going to fast food restaurants with his

friends.

c. Encourage him to find activities to do with his friends that do not involve eating.

d. Assist him in identifying popular fast foods that are within his meal plan for diabetes.

40. A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be

allowed to die. The client states that he is tired of fighting his illness and is only continuing

treatments because his family wants him to live. Which action should the nurse take?

a. Notify the family that treatments have been discontinued.

b. Arrange a meeting with the family, physician, and client.

c. Ask the chaplain to discuss death issues with the client.

d. Request a consultation with the hospital social worker.

41. Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and

difficulty in breathing….. had a pulmonary embolus. What action should the nurse take first?

a. Bring the emergency crash cart to the bedside.

b. Prepare a continuous heparin infusion per protocol.

c. Provide supplemental oxygen.

d. Notify the healthcare provider.

42. A client admitted with a liver abscess is scheduled for surgical evacuation and drainage of the

abscess tomorrow morning. Nursing assess …. Client’s abdominal pain has increased from 4 to 8

on a 10-point scale in the last four hours. What is priority nursing action?

a. Notify the surgeon of increasing abdominal pain.

b. Administer the nest scheduled dose of antibiotic.

c. Encourage the client to cough and deep breath.

d. Assess for a change in the client’s bowel sounds.

43. A female client with chronic kidney disease and renal failure has an indwelling peritoneal

catheter in ….. used for peritoneal dialysis. While bathing, the her abdominal dressing becomes

wet. What action should the nurse take?

a. Change the dressing.

b. Reinforce the dressing.

c. Flush the peritoneal dialysis catheter.

d. Scrub the catheter with povidone-iodine.

44. The nurse is developing a plan of care for an older male client with type 2 diabetes who reports

blurred vision. Which outcome shows a plan of care for this client?

a. The client will express acceptance of his changing health status.

b. The client’s family will state signs and symptoms about the disease.

c. The nurse will demonstrate the procedure for accurate eye care.

d. The client’s daily blood pressure will be less than 140/80 mmHg this month.

45. The nurse identifies an electrolyte imbalance, an elevated pulse rate, and a weight gain of 4.4

lbs (2 kg) in 24 hours for a client with chronic kidney disease. What intervention should the

nurse include in the plan of care?

a. Monitor serum electrolytes daily.

b. Provide only distilled water.

c. Document abdominal girth.

d. Perform range of motion exercises.

46. A client with postpartum depression, who is admitted to the behavioral health unit, refuses to

leave her room or eat meals. In addition to patient’s safety, which short-term goal should the

nurse include in the plan of care?

a. Attends one group activity per day.

b. Sleeps at least 6 hours per night.

c. Engages in one client-to-client interaction daily.

d. Consumes 3 meals and 1500 mL of fluid per day.

47. Which information is a priority for the RN to reinforce to an older client after

intravenous pyelogram?

a. Eat a light diet for the rest of the day

b. Rest for the next 24 hours since the preparation and the test is tiring.

c. During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days

d. Measure the urine output for the next day and immediately notify the health care provider if it

should decrease.

48. A client has altered renal function and is being treated at home. The nurse recognizes

that the most accurate indicator of fluid balance during the weekly visits is

a. Difference in the intake and output

b. Changes in the mucous membranes

c. Skin turgor

d. Weekly weight

49. A client has been diagnosed with Zollinger-Ellison syndrome.Which information is

most important for the nurse to reinforce with the client?

a. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the

upper part of the small intestine (duodenum)

b. It is critical to report promptly to your health care provider any findings of peptic ulcers

c. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible,

surgery to remove any tumors

d. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the

stomach or intestine

50. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse

determines that the client’s blood pressure is increasing. Which action should the nurse

take first?

a. Check the protein level in urine

b. Have the client turn to the left side

c. Take the temperature

d. Monitor the urine output

51. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the

ventricular rate is controlled at 75. Which of the following findings is cause for the most

concern?

a. Diminished bowel sounds

b. Loss of appetite

c. A cold, pale lower leg

d. Tachypnea

52. The client with infective endocarditis must be assessed frequently by the home health

nurse. Which finding suggests that antibiotic therapy is not effective, and must be

reported by the nurse immediately to the healthcare provider?

A) Nausea and vomiting

B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)

C) Diffuse macular rash

D) Muscle tenderness

53. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which

of these points is most important to be reinforced by the nurse?

A) Until the health care provider has determined that your ejaculate doesn't contain

sperm, continue to use another form of contraception.

B)This procedure doesn't impede the production of male hormones or the production of

sperm in the testicles. The sperm can no longer enter your semen and no sperm are in

your ejaculate.

C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If

your work doesn't involve hard physical labor, you can return to your job as soon as you

feel up to it. The stitches

generally dissolve in seven to ten days.

D)The health care provider at this clinic recommends rest, ice, an athletic supporter or

over-the-counter pain medication to relieve any discomfort.

54. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being

sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client

would be incorrect about acupuncture?

A)Some needles go as deep as 3 inches, depending on where they're placed in the body

and what the treatment is for. The needles usually are left in for 15 to 30 minutes.

B) In traditional Chinese medicine, imbalances in the basic energetic flow of life —

known as qi or chi — are thought to cause illness.

C) The flow of life is believed to flow through major pathways or nerve clusters in your

body.

D) By inserting extremely fine needles into some of the over 400 acupuncture points in

various combinations it is believed that energy flow will rebalance to allow the body's

natural healing

mechanisms to take over.

55. The nurse is discussing with a group of students the disease Kawasaki. What statement

made by a student about Kawasaki disease is incorrect?

A) It also called mucocutaneous lymph node syndrome because it affects the mucous

membranes (inside the mouth, throat and nose), skin and lymph nodes.

B) In the second phase of the disease, findings include peeling of the skin on the hands

and feet with joint and abdominal pain

C) Kawasaki disease occurs most often in boys, children younger than age 5 and children

of Hispanic descent

D) Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which

lasts 1 to2 weeks

56. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best

position to teach the client to lie in every other hour during first 12 hours after admission?

A) Side-lying on the left with the head elevated 10 degrees

B) Side-lying on the left with the head elevated 35 degrees

C) Side-lying on the right with the head elevated 10 degrees

D) Side-lying on the right with the head elevated 35 degrees

57. A client has an indwelling catheter with continuous bladder irrigation after

undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding

at this time should be reported to the health care provider?

A) Light, pink urine

B) occasional suprapubic cramping

C) minimal drainage into the urinary collection bag

D) complaints of the feeling of pulling on the urinary catheter

58. A nurse is performing CPR on an adult who went into cardiopulmonary arrest.

Another nurse enters the room in response to the call. After checking the client’s pulse

and respirations, what should

be the function of the second nurse?

A) Relieve the nurse performing CPR

B) Go get the code cart

C) Participate with the compressions or breathing

D) Validate the client's advanced directive

59. The nurse assesses a 72 year-old client who was admitted for right sided congestive

heart failure. Which of the following would the nurse anticipate finding?

A) Decreased urinary output

B) Jugular vein distention

C) Pleural effusion

D) Bibasilar crackles

60. A client with heart failure has a prescription for digoxin. The nurse is aware that

sufficient potassium should be included in the diet because hypokalemia in combination

with this medication

A) Can predispose to dysrhythmias

B) May lead to oliguria

C) May cause irritability and anxiety

D) Sometimes alters consciousness

61. A nurse assesses a young adult in the emergency room following a motor vehicle

accident. Which of the following neurological signs is of most concern?

A) Flaccid paralysis

B) Pupils fixed and dilated

C) Diminished spinal reflexes

D) Reduced sensory responses

62. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a

diagnosis of vaso-occlusive crisis. Which statements by the client would be most

indicative of the etiology of this crisis?

A)”I knew this would happen. I've been eating too much red meat lately."

B)”I really enjoyed my fishing trip yesterday. I caught 2 fish."

C)”I have really been working hard practicing with the debate team at school."

D)”I went to the health care provider last week for a cold and I have gotten worse."

63. Which these findings would the nurse more closely associate with anemia in a 10

month-old infant?

A) Hemoglobin level of 12 g/dI

B) Pale mucosa of the eyelids and lips

C) Hypoactivity

D) A heart rate between 140 to 160

64. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The

priority assessment in the first hour of care is

A) Heart rate

B) Pedal pulses

C) Lung sounds

D) Pupil responses

65. Which of these clients who are all in the terminal stage of cancer is least appropriate

to suggest the use of patient controlled analgesia (PCA) with a pump?

A) A young adult with a history of Down's syndrome

B) A teenager who reads at a 4th grade level

C) An elderly client with numerous arthritic nodules on the hands

D) A preschooler with intermittent episodes of alertness

66. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive

(NOFTT). Upon entering the room, the nurse would expect the baby to be

A) Irritable and "colicky" with no attempts to pull to standing

B) Alert, laughing and playing with a rattle, sitting with support

C)Skin color dusky with poor skin turgor over abdomen

D) Pale, thin arms and legs, uninterested in surroundings

67. As the nurse is speaking with a group of teens which of these side effects of

chemotherapy for cancer would the nurse expect this group to be more interested in

during the discussion?

A) Mouth sores

B) Fatigue

C) Diarrhea

D) Hair loss

68. While caring for a client who was admitted with myocardial infarction (MI) 2 days

ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees

Celsius). The appropriate

nursing intervention is to

A) Call the health care provider immediately

B) Administer acetaminophen as ordered as this is normal at this time

C) Send blood, urine and sputum for culture

D) Increase the