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Hesi practice exam evolve 131 Questions and Answers latest 2025 Graded A+.pdf, Exams of Nursing

University of West London (UWL)Nursing

Hesi practice exam evolve 131 Questions and Answers latest 2025 Graded A+.pdf

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Hesi practice exam evolve 131
Questions and Answers latest 2024-
2025 Graded A+
Hesi practice exam evolve 131
Questions and Answers latest 2025
Graded A+
An adult client who is hospitalized after surgery reports sudden onset of chest pain
and dyspnea. The client appears anxious, restless, and mildly cyanotic. The nurse
should further assess the client for which condition?
- pulmonary embolism
- heart failure
- tuberculosis
- bronchitis - Ans
pulmonary embolism
Which information should the nurse obtain when performing an initial assessment of
a client who presents to the emergency department with a painful ankle injury?
(Select all that apply.)
- quality of the pain
- signs of inflammation
- ankle range of motion
- muscle strength testing
- visible deformities of the joint- Ans
- quality of the pain
- signs of inflammation
- ankle range of motion
- visible deformities of the joint
Which description of pain is consistent with a diagnosis of rheumatoid arthritis?
- joint pain is worse in the morning and involves symmetric joints
- joint pain is better in the morning and worsens throughout the day
- joint pain is consistent throughout the day and is relieved by pain medication
- joint pain is worse during the day and involves unilateral joints - Ans
joint pain is worse in the morning and involves symmetric joints
Which physical assessment finding should the nurse anticipate in a client with long-
term gastroesophagealreflux disease (GERD)?
- hoarseness
- dry mouth
- mouth ulcers
- weight loss - Ans
hoarseness
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Download Hesi practice exam evolve 131 Questions and Answers latest 2025 Graded A+.pdf and more Exams Nursing in PDF only on Docsity!

Questions and Answers latest 202 4 -

2025 Graded A+

Hesi practice exam evolve 131

Questions and Answers latest 202 5

Graded A+

An adult client who is hospitalized after surgery reports sudden onset of chest pain and dyspnea. The client appears anxious, restless, and mildly cyanotic. The nurse should further assess the client for which condition?

  • pulmonary embolism
  • heart failure
  • tuberculosis
  • bronchitis - Ans pulmonary embolism Which information should the nurse obtain when performing an initial assessment of a client who presents to the emergency department with a painful ankle injury? (Select all that apply.)
  • quality of the pain
  • signs of inflammation
  • ankle range of motion
  • muscle strength testing
  • visible deformities of the joint- Ans
    • quality of the pain
  • signs of inflammation
  • ankle range of motion
  • visible deformities of the joint Which description of pain is consistent with a diagnosis of rheumatoid arthritis?
  • joint pain is worse in the morning and involves symmetric joints
  • joint pain is better in the morning and worsens throughout the day
  • joint pain is consistent throughout the day and is relieved by pain medication
  • joint pain is worse during the day and involves unilateral joints - Ans joint pain is worse in the morning and involves symmetric joints Which physical assessment finding should the nurse anticipate in a client with long- term gastroesophagealreflux disease (GERD)?
  • hoarseness
  • dry mouth
  • mouth ulcers
  • weight loss - Ans hoarseness

Questions and Answers latest 202 4 -

2025 Graded A+

A client presents with chronic venous insufficiency. Which assessment finding should the nurse anticipate?

  • bilateral lower leg stasis dermatitis
  • clubbing of fingers and toes
  • intermittent claudication
  • peripheral cyanosis - Ans bilateral lower leg stasis dermatitis A client has been hospitalized with a femur fracture and is being treated with traction. Which action by the nurse is the priority when caring for this client?
  • assess neurovascular status
  • change the client's position
  • inspect the traction equipment
  • review pain medication orders - Ans assess neurovascular status Which statement made by a client with chronic pancreatitis indicates that further education is needed?
  • I will cut back on smoking cigarettes daily
  • I will avoid drinking caffeinated beverages
  • I will rest frequently and avoid vigorous exercise
  • I will eat a bland, low-fat, high-protein diet - Ans I will cut back on smoking cigarettes daily (*avoid nicotine entirely) The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.)
  • remove the diaphragm immediately after intercourse
  • wash the diaphragm with an alcohol solution
  • use the diaphragm to prevent conception during the menstrual cycle
  • do not leave the diaphragm in place longer than 8 hours after intercourse
  • replace the old diaphragm every 3 months - Ans
    • do not leave the diaphragm in place longer than 8 hours after intercourse
  • replace the old diaphragm every 3 months A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.)
  • marijuana cigarettes do not affect sperm count
  • alcohol consumption can cause erectile dysfunction
  • low testosterone levels affect sperm production
  • cessation of smoking improves general health and fertility
  • obesity has no effect on sperm production - Ans

Questions and Answers latest 202 4 -

2025 Graded A+

young adult male is diagnosed with Stage 4 Hodgkin's lymphoma in the abdominopelvic region and is scheduled for radiation therapy (RT). The client expresses concern about becoming infertile. How should the nurse respond?

  • propose sperm banking before RT then artificial insemination is an option
  • suggest adoption when the client is in remission or ready for parenting
  • tell the client that infertility is a non-reversible side effect of radiotherapy
  • explain that sperm production will be suppressed after radiotherapy is over - Ans propose sperm banking before RT then artificial insemination is an option A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history?
  • Jewish European ancestry
  • H. pylori bowel infection
  • family history of irritable bowel syndrome
  • age between 25 and 55 years - Ans Jewish European ancestry Small bowel obstruction is a condition characterized by which finding?
  • severe fluid and electrolyte imbalances
  • metabolic acidosis
  • ribbon-like stools
  • intermittent lower abdominal cramping - Ans severe fluid and electrolyte imbalances Which client should the nurse recognize as most likely to experience sleep apnea?
  • middle-aged female who takes a diuretic nightly
  • obese older male client with a short, thick neck
  • adolescent female with a history of tonsillectomy
  • school-aged male with a history of hyperactivity disorder - Ans obese older male client with a short, thick neck Which milestone indicates to the nurse successful achievement of young adulthood?
  • demonstrates a conceptualization of death and dying
  • completes education and becomes self-supporting
  • creates a new definition of self and roles with others
  • develops a strong need for parental support and approval - Ans completes education and becomes self-supporting A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
  • give 20 mEq of potassium chloride
  • initiate continuous cardiac monitoring
  • arrange a consultation with the dietician
  • teach about the side effects of diuretics - Ans initiate continuous cardiac monitoring

Questions and Answers latest 202 4 -

2025 Graded A+

Which postmenopausal client's complaint should the nurse refer to the healthcare provider?

  • breasts feel lumpy when palpated
  • history of white nipple discharge
  • episodes of vaginal bleeding
  • excessive diaphoresis occurs at night - Ans episodes of vaginal bleeding The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide?
  • two weeks before menstruation
  • vaginal mucous discharge is thick
  • low basal temperature
  • first thing in the morning - Ans two weeks before menstruation A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. Which response is best for the nurse to provide?
  • estrogen deficiency causes the vaginal tissues to become dry and thinner
  • infrequent intercourse results in the vaginal tissues losing their elasticity
  • dehydration from inadequate fluid intake causes vulva tissue dryness
  • lack of adequate stimulation is the most common reason for dyspareunia - Ans estrogen deficiency causes the vaginal tissues to become dry and thinner Which discharge instruction is most important for a client after a kidney transplant?
  • weigh weekly
  • report symptoms of secondary candidiasis
  • use daily reminders to take immunosuppressants
  • stop cigarette smoking - Ans use daily reminders to take immunosuppressants The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first?
  • potassium 6.0 mEq
  • daily urine output of 400 ml
  • peripheral neuropathy
  • uremic fetor - Ans potassium 6.0 mEq Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)?
  • hematuria
  • 2 pounds weight gain
  • 3+ bacteria in urine
  • Steady, dull flank pain - Ans 3+ bacteria in urine

Questions and Answers latest 202 4 -

2025 Graded A+

After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 mL for the last 2 hours. Which priority nursing action should be implemented?

  • report the findings to the surgeon
  • irrigate the indwelling urinary catheter
  • apply manual pressure to the bladder
  • increase the IV flow rate for 15 minutes - Ans report the findings to the surgeon A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority?
  • listen to bilateral lung and bowel sounds
  • obtain the client's pulse and blood pressure
  • assist the client to the bathroom to void
  • check the client's gag and swallow reflexes - Ans check the client's gag and swallow reflexes During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide?
  • neither plan allows selections of healthcare providers or hospitals
  • there are fewer healthcare providers to choose from than in an HMO plan
  • an individual may select healthcare providers from outside of the PPO network
  • an individual can become a member of a PPO without belonging to a group - Ans an individual may select healthcare providers from outside of the PPO network The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include?
  • limit dietary selection of cholesterol to 300 mg per day
  • increase intake of soluble fiber to 10 to 25 grams per day
  • decrease plant stanols and sterols to less than 2 grams/day
  • ensure saturated fat is less than 30% of total caloric intake - Ans increase intake of soluble fiber to 10 to 25 grams per day A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take?
  • determine the client is anxious and allow him to sleep
  • evaluate his blood pressure, pulse, and respiratory status
  • review the client's pre-operative history for alcohol abuse
  • continue to monitor the client for reactivity to anesthesia- Ans evaluate his blood pressure, pulse, and respiratory status

Questions and Answers latest 202 4 -

2025 Graded A+

A client who is sexually active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide?

  • using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID)
  • getting pregnant while using an IUD is common and is not the best contraceptive choice
  • relying on an IUD may be a safer choice for monogamous partners, but a barrier method provides a better option in preventing STD transmission
  • selecting a contraceptive device should consider choosing a successful method used in the past - Ans using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID) A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain?
  • amount of weight gain or weight loss during the previous year
  • an accurate menstrual cycle diary for the past 6 to 12 months
  • skin pigmentation and hair texture for evidence of hormonal changes
  • previous birth-control methods and beliefs about the calendar method - Ans an accurate menstrual cycle diary for the past 6 to 12 months A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints?
  • frequent urinary tract infections.
  • inability to get pregnant
  • premenstrual syndrome
  • chronic use of laxatives - Ans inability to get pregnant A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?
  • "Check it again in one month, and if it is still there schedule an appointment."
  • "Most lumps are benign, but it is always best to come in for an examination."
  • "Try not to worry too much about it, because usually, most lumps are benign."
  • "If you are in your menstrual period it is not a good time to check for lumps." - Ans "Most lumps are benign, but it is always best to come in for an examination." The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. Which recommendation should the nurse make that is most beneficial in protecting the client's joints?
  • increase the amount of calcium intake in the diet
  • apply alternating heat and cold therapies
  • initiate a weight-reduction diet to achieve a healthy body weight
  • use a walker for ambulation to lessen weight-bearing on the hips - Ans initiate a weight-reduction diet to achieve a healthy body weight

Questions and Answers latest 202 4 -

2025 Graded A+

  • give an antihypertensive medication - Ans give an antihypertensive medication A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency?
  • dyspnea
  • nocturia
  • confusion
  • stomatitis - Ans nocturia The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care?
  • flush the tube with 50 ml of water q 8 hours
  • check for tube placement and residual volume q4 hours
  • obtain a daily x- ray to verify tube placement
  • position on left side with head of bed elevated 45 degrees - Ans check for tube placement and residual volume q4 hours The nurse is planning care to prevent complications for a client with multiple myeloma. Which intervention is most important for the nurse to include?
  • safety precautions during activity
  • assess for changes in size of lymph nodes
  • maintain a fluid intake of 3 to 4 L per day
  • administer narcotic analgesic around the clock - Ans maintain a fluid intake of 3 to 4 L per day When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide?
  • place a small book or magazine on the abdomen and make it rise while inhaling deeply
  • purse the lips while inhaling as deeply as possible and then exhale through the nose
  • wrap a towel around the abdomen and push against the towel while forcefully exhaling
  • place one hand on the chest, one hand the abdomen and make both hands move outward - Ans place a small book or magazine on the abdomen and make it rise while inhaling deeply During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first?

Questions and Answers latest 202 4 -

2025 Graded A+

  • notify the healthcare provider for reinsertion
  • attempt to reinsert the tracheostomy tube
  • position the client in a lateral position with the neck extended
  • ventilate client's tracheostomy stoma with a manual bag-mask - Ans attempt to reinsert the tracheostomy tube A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the healthcare provider?
  • lung tissue biopsy
  • positive blood cultures
  • magnetic resonance imaging (MRI)
  • computerized tomography (CT) of the thorax - Ans lung tissue biopsy How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?
  • positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line
  • positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line
  • positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder
  • negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line - Ans negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?
  • "I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight."
  • "I will let you have one cracker, but that is all you can have for the rest of tonight."
  • "What did the healthcare provider tell you about the test you are having tomorrow?"
  • "The test you are having tomorrow requires that you have nothing by mouth tonight." - Ans "The test you are having tomorrow requires that you have nothing by mouth tonight." The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. Which action should the nurse implement?
  • prepare the client for transcutaneous pacemaker
  • shock the client with 200 joules per hospital policy
  • use a magnet to deactivate the implanted pacemaker
  • observe the monitor until the onset of ventricular fibrillation - Ans

Questions and Answers latest 202 4 -

2025 Graded A+

  • anticoagulants and expectorants
  • bronchodilators and steroids - Ans bronchodilators and steroids A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration?
  • serum creatinine
  • blood Urea Nitrogen (BUN)
  • sedimentation rate
  • urine specific gravity - Ans serum creatinine Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. Which intervention would be most helpful to this client?
  • apply sequential compression devices (SCDs) bilaterally
  • assess for a positive Homan's sign in each leg
  • pad all bony prominences on the affected leg
  • advise the client to remain in bed with the leg elevated - Ans advise the client to remain in bed with the leg elevated Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?
  • place HIV positive clients in strict isolation and limit visitors
  • wear gloves when coming in contact with the blood or body fluids of any client
  • conduct mandatory HIV testing of those who work with AIDS clients
  • freeze HIV blood specimens at - 70 F to kill the virus - Ans wear gloves when coming in contact with the blood or body fluids of any client A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. Which content is most important for the nurse to include in the discharge teaching for this client?
  • information about smoking cessation
  • diet instructions for a low-residue diet
  • instructions on a weight-loss program
  • the importance of increasing milk in the diet - Ans information about smoking cessation In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer?
  • a 35-year-old multipara who never breastfed
  • a 50-year-old whose mother had unilateral breast cancer
  • a 55-year-old whose mother-in-law had bilateral breast cancer
  • a 20-year-old whose menarche occurred at age 9 - Ans a 50-year-old whose mother had unilateral breast cancer

Questions and Answers latest 202 4 -

2025 Graded A+

An adult client is admitted to the hospital burn unit with partial-thickness and full- thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, which should the nurse remember about full-thickness burns?

  • regenerative function of the skin is absent because the dermal layer has been destroyed
  • tissue regeneration will begin several days following return of normal circulation
  • debridement of eschar will delay the body's ability to regenerate normal tissue
  • normal tissue formation will be preceded by scar formation for the first year - Ans regenerative function of the skin is absent because the dermal layer has been destroyed A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result would the nurse expect this client to exhibit?
  • elevated LDH
  • elevated serum amylase
  • elevated CK-MB
  • elevated hematocrit- Ans elevated CK-MB The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit?
  • a decreased total lung capacity
  • normal arterial blood gases
  • normal skin coloring
  • an absence of sputum - Ans normal skin coloring (pink puffer vs blue bloater) A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints?
  • prevention of deformities
  • avoidance of joint trauma
  • relief of joint inflammation
  • improvement in joint strength - Ans prevention of deformities A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement?
  • release the traction q4h to provide skin care

Questions and Answers latest 202 4 -

2025 Graded A+

A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia?

  • "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant."
  • "Alopecia is a common side effect you will experience during long-term steroid therapy."
  • "Your hair will grow back completely after your course of chemotherapy is completed."
  • "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss." - Ans "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which clinical cues should the nurse describe when teaching the client about hypoglycemia?
  • sweating, trembling, tachycardia
  • polyuria, polydipsia, polyphagia
  • nausea, vomiting, anorexia
  • fruity breath, tachypnea, chest pain - Ans sweating, trembling, tachycardia A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. Which action should the nurse implement?
  • determine if the client has also experienced breast tenderness and weight gain
  • encourage the client to begin a regular, daily program of walking and exercise
  • advise the client to notify the healthcare provider for immediate medical attention
  • tell the client to stop taking the medication for a week to see if symptoms subside - Ans advise the client to notify the healthcare provider for immediate medical attention The healthcare provider prescribes aluminum and magnesium hydroxide, 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. Which intervention should the nurse implement?
  • administer 30 minutes before eating
  • evaluate the effectiveness 1 hour after administration
  • instruct the client to swallow the tablet whole
  • question the healthcare provider's prescription - Ans question the healthcare provider's prescription (Mg agents not usually indicated with CKD due to risk of hypermagnesemia) A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse?
  • white blood count of 10,000 mm

Questions and Answers latest 202 4 -

2025 Graded A+

  • serum glucose of 115 mg/dl
  • purulent sputum
  • excessive hunger - Ans purulent sputum (indicates infection) A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide?
  • stay out of direct sunlight
  • restrict intake of high protein foods
  • schedule extra rest periods
  • go to the emergency room immediately - Ans schedule extra rest periods The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?
  • cyanosis of the fingertips
  • bradycardia and bradypnea
  • presence of S3 and S4 heart sounds
  • 3+ pitting edema of the lower extremities - Ans cyanosis of the fingertips A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information?
  • the vaccine is given annually before the flu season to those over 50 years of age
  • the immunization is administered once to older adults or persons with a history of chronic illness
  • the vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection
  • the vaccine will prevent the occurrence of pneumococcal pneumonia for up to five years - Ans the immunization is administered once to older adults or persons with a history of chronic illness An elderly client is admitted with a diagnosis of bacterial pneumonia. When observing the client for the first signs of decreasing oxygenation, the nurse should assess for which clinical cues?
  • abdominal distention
  • undue fatigue
  • cyanosis of the lips
  • confusion and tachycardia - Ans confusion and tachycardia

Questions and Answers latest 202 4 -

2025 Graded A+

  • a brief description of each resident's family life
  • the age of each group member
  • the usual activity patterns of each member of the group - Ans the usual activity patterns of each member of the group While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test?
  • immediately after the exposure
  • within one week of the exposure
  • four to six weeks after the exposure
  • three months after the exposure - Ans four to six weeks after the exposure A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing assessment is of greatest importance to this client?
  • pulse rate, both apically and radially
  • blood pressure, both standing and sitting
  • temperature
  • skin color and turgor - Ans temperature During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. Which would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope?
  • this is a normal auscultatory finding
  • may indicate pneumothorax
  • may indicate pneumonia
  • may indicate severe emphysema - Ans may indicate pneumonia The nurse is performing an ophthalmoscopic examination on a hypertensive client. When assessing the client, which finding indicates the severity of hypertension?
  • opaguecolor of the sclera
  • transparency of the cornea
  • amount of retinal vessel damage that has occurred
  • constriction and dilatation of the pupils - Ans amount of retinal vessel damage that has occurred The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain?
  • if suctioning will be needed for drainage of the wound
  • if the family would prefer a private or semi-private room
  • prescription for removal of the drain

Questions and Answers latest 202 4 -

2025 Graded A+

  • if the client's wound is infected - Ans if the client's wound is infected The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. Which nursing action is best for the nurse to implement?
  • ask the client what he means by "heart trouble."
  • call for an ECG to be performed immediately
  • notify surgery that the ECG is over two years old
  • notify the client's surgeon immediately - Ans call for an ECG to be performed immediately The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)?
  • diabetes mellitus
  • hypothyroidism
  • parkinson's disease
  • recurring pneumonia - Ans diabetes mellitus (2-4x more likely. excess glucose leading to incr fatty deposits/clots) The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care?
  • "Have you ever experienced any paralysis of your arms or legs?"
  • "Have you ever sustained a severe head injury?"
  • "Have you ever been 'frozen' in one spot, unable to move?"
  • "Do you have headaches, especially ones with throbbing pain?" - Ans "Have you ever been 'frozen' in one spot, unable to move?" The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. Which symptoms would this client most likely exhibit?
  • loss of short-term memory, facial tics and grimaces, and constant writhing movements
  • shuffling gait, masklike facial expression, and tremors of the head
  • extreme muscular weakness, easy fatigability, and ptosis
  • numbness of the extremities, loss of balance, and visual disturbances - Ans shuffling gait, masklike facial expression, and tremors of the head Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation?
  • maintain the residual limb on three pillows at all times