A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast,
which instructions should the nurse provide to the parents?
a. Blow cool air from a hair dryer under the cast
b. Twist the cast back and forth
c. Shake powder into the cast
d. Push a pencil under the cast edge
A client in the oliguric phase of acute renal failure (ARF) has a 24-hour urine output of 400 ml. The
nurse should allow this client to have how much oral intake during the next 24 hours?
a. Encourage oral fluids as tolerated
b. Decrease oral intake to 200 ml
c. Allow the client to have exactly 400 ml oral intake
UPPERGRADES 1
, 2
HESI Computerized Adaptive Testing (CAT)
d. Limit oral intake to 900 to 1,000 ml
A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom
floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks
what happened. She doesn't respond. What should the nurse do next?
a. Find supplies to put a dressing on the client's wrist
b. Take the client to a room for supervision by staff
c. Call the healthcare provider to report the client's behaviour
d. Go find a staff to stay in the room with the client
What assessment technique should the nurse use to monitor a client for a common untoward effect of
phenytoin (Dilantin)?
a. Bladder palpation
b. Inspection of the mouth
c. Blood glucose monitoring
d. Auscultation of breath sounds
The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory
value is most important for the nurse to monitor?
a) Calcium
b) Sodium
c) Chloride
d) Potassium
The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client
experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, what do
you think you're doing? How should the nurse respond?
a. I cannot give you this medication until you calm down
b. This shot will help relieve the pain in your feet.
c. Would you prefer to learn to administer your own shot
d. You will feel calmer and less jittery after this shot
When administering an intramuscular injection containing 3 ml of a painful medication, which
intervention should the nurse implement?
UPPERGRADES 2
, 3
HESI Computerized Adaptive Testing (CAT)
a. Instill the medication quickly
b. Insert the needle slowly
c. Select a large, deep muscle mass
d. Use a short small gauge needle
Several clients on a telemetry unit are schedule for discharge in the morning, but a telemetry-
monitored bed is needed immediately. The charge nurse should make arrangements to transfer which
client to another medical unit? The client who is
a. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
b. Ambulatory following coronary artery bypass graft surgery performed six days ago.
c. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
d. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhoea
The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the
new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically
ill client. What findings should the new graduate nurse identifies?
a. Tachycardia, mental status change, and low urine output
b. Warm skin, hypertension, and constricted pupils
c. Bradycardia, hypotension, and respiratory acidosis
d. Mottled skin, tachypnea and hyperactive bowel sounds
The nurse is making assignments for a new graduate from a practical nursing program that is orienting
to the unit. Because the unit is particularly busy this day, there will be little time to provide
supervision of this new employee. Which client is the best for the nurse to assign this newly graduate
practical nurse? A client
a. Whose discharge has been delayed because of a postoperative infection
b. With poorly controlled type 2 diabetes who is sliding scale for insulin administration
c. Newly admitted with a head injury who requires frequent assessments
d. Who is receiving IV heparin that is regulated based on protocol
Nurses working in labor and delivery are demanding a change in policy because they believe they are
required to float more often than nurses on other units. However, floating to labor and delivery is not
reciprocated because other nurses are not competent to provide highly specialized obstetrical skills.
What action is best for the nurse-manager to implement?
a. Require the other nurses to cross-train for obstetrics
UPPERGRADES 3
, 4
HESI Computerized Adaptive Testing (CAT)
b. Propose a method for self-staffing labor and delivery
c. Remind nurses that floating is an administrative policy
d. Encourage nurses to share their feelings with administration
The nurse has explained safety precautions and infant care to a primigravida mother and observes the
mother, as gives care to her newborn during the first two days of rooming-in. Which action indicates
the mother understand the instruction?
a. Aspirates the newborn's nares using syringe
b. Applies a dressing on the cord after the newborn's bath
c. Breastfeeds the infant every hour during the night
d. Positions the infant supine in the crib to sleep
The nurse teaches the mother of a 6 year-old anemic boy to give iron supplements. Which statement
indicates that the mother understands the proper administration of iron?
a. The iron tablets will be absorbed between meals, on an empty stomach
b. I should give the iron tablets with his milk and cereal each morning
c. Iron preparations can be taken with antibiotics if he develops an infection
d.The iron tablets may cause him to sunburn more easily so he should wear sunscreen
Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with
pneumonia. Which nursing intervention is effective in preventing oxygen toxicity? Oxygen at
liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which
nursing intervention is effective in preventing oxygen toxicity?
a. Avoiding the administration of oxygen at high levels for extended periods.
b. Administering a sedative at bedtime to slow the client's respiratory rate
c. Removing the nasal cannula during the night to prevent oxygen buildup
d. Running oxygen through a hydration source prior to administration
The healthcare provider prescribes amoxicillin (Amoxil) 1.5 grams PO daily, in equally divided doses
to be administer every 8 hours. The medication is available in a bottle labelled, Amoxicillin (Amoxil)
suspension 200 mg/5 ml. How many ml should the nurse administer every 8 hours? (Enter numeric
value only. If rounding is required, round to the nearest tenth.)
[Ans: - 12.5
A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and
her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her
UPPERGRADES 4
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