ALL HESI EXIT QUESTIONS AND ANSWERS TEST BANK; A+ RATED GUIDE
A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What
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should the nurse take?
(correct Answer- Administer the medication as prescribed with a glass of water
Which client should the nurse assess frequently because of the risk for overflow incontinence?
A client Who is confused and frequently forgets to go to the bathroom
While monitoring a client during a seizure, which interventions should the nurse implement? (Select
all that apply)
(correct AnswerMove obstacle away from client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure
A male client with a long history of alcoholism is admitted because of mild confusion and fine
motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month
ago after his brother died of lung cancer.
Which intervention is most important for the nurses to include in the client's plan of care?
(correct Answer- Observe for changes in level of consciousness.
An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated
with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute.
The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2
98%, HCO3 23. To normalize the client's ABG finding, which action is required?
correct Answer- Increase ventilator rate.
The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing
increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also
experiences a loss of appetite. What instruction should the nurse provide?
(correct Answer- CPT should be performed more frequently, but at least an hour before meals.
The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection
indicates that the client understands the dietary recommendation for hypertension?
(correct Answer- Baked pork chop, applesauce, corn on the cob, 2% milk, and key- lime pie
A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a
glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at
bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse
include in this client's plan of care?
(correct Answer- Fingerstick glucose assessment q6h with meals Review with the client proper footcare and prevention of injury
Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous
injection technique, site rotation and insulin management
Which problem reported by a client taking lovastatin requires the most immediate fallow up by the
nurse?
(correct Answer- Muscle pain
While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of
the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart
rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which
interventions should the nurse implement?
(correct Answer- Provide supplemental oxygen Auscultate bilateral lung fields
Reinforce occlusive CT dressing
Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach
the client's wrist restraints to the movable portion of the client's bed frame. What action should the
nurse take before leaving the room?
(correct Answer- Ensure that the knot can be quickly released.
Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine
and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse
emphasize concerning the installation of the antipyrine/benzocaine otic solution?
(correct Answer- Have the child lie with the ear up for one to two minute after installation.
An older adult male is admitted with complications related to chronic obstructive pulmonary
disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has
increased over the past month. The nurse notes that he has dependent edema in both lower legs.
Based on these assessment findings, which dietary instruction should the nurse provide?
(correct Answer- Restrict daily fluid intake.
The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse
take next?
(correct Answer- Leave the catheter in place and obtain a sterile catheter.
A client with coronary artery disease who is experiencing syncopal episodes is admitted for an
electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the
nurse delegate to the unlicensed assistive personnel (UAP)?
(correct Answer- Prepare the skin for procedure.
Fallowing an outbreak of measles involving 5 students in an elementary school, which action is
most important for the school nurse to take? (correct Answer- Restrict unvaccinated children from
attending school until measles outbreak is resolved.
A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She
continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml perhour, and her urinary output for the last hour was 850 ml. What intervention should the nurse
implement?
(correct Answer- Continue with the plan of care for this client
The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior
indicates the highest risk for the client acting on these suicidal thoughts?
(correct Answer- Begin to show signs of improvement in affect
When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of
lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should
the nurse implement first?
(correct Answer- Check for a destined bladder
A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50
ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement?
(correct Answer- Encourage popsicles and fluids of choice
An older male client arrives at the clinic complaining that his bladder always feels full. He
complains of weak urine flow, frequent dribbling after voiding, and
increasing nocturia with difficulty initiating his urine stream. Which action should the nurse
implement?
(correct Answer- Palpate the client's suprapubic area for distention
The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action
should the nurse include?
(correct Answer- Divide the medication into two injection with volumes under 1ml
A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and
ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be
most helpful?
(correct Answer- Research indicates that mirror therapy is effective in reducing phantom limb pain
An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled,
distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration,
which intervention is most important for the nurse to implement?
(correct Answer- Notify healthcare provider to prepare for pericardiocentesis
A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits
on a third chair. The members of the group are forced to move closer and remove their possessions
from the table what action should the nurse leader take?
(correct Answer- Ask the new person to move belonging to accommodate othersThe nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was
placed 2 days after birth. Which findings are an indication of a postoperative complication?
(correct Answer- Poor feeding and vomiting Leakage of CSF from the incisional site Abdominal
distention
The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds.
Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of
1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value
only) (
correct Answer- 8
In monitoring tissue perfusion in a client following an above the knee amputation (aka), which
action should the nurse include in the plan of care? (correct Answer- Evaluate closet proximal
pulse.
The leg of a client who is receiving hospice care have become mottled in appearance. When the
nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas,
what action should the nurse take? (correct Answer- Remove the heating pads and place a soft
blanket over the client's leg and feet.
A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet
management. What dietary instruction is most important for the nurse to explain to the client?
(correct Answer- Plan volume-controlled evenly- space meal thorough the day
If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes,
flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium
concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? (correct
Answer- Insensible loss of body fluids contributes to the hemoconcentration of serum solutes
During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is
working with a register nurse (RN) (correct Answer- Prepare a woman for a bone density screening
An adult client present to the clinic with large draining ulcers on both lower legs that are
characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member.
Which action should the nurse take? (correct Answer- Send family to the waiting area while the
client's history is taking
An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The
client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a
new business and "I'm too busy to eat". The
client is oriented to time, place, person but not situation. Which nursing problem has the greatest
priority? (correct Answer- Imbalance nutrition
The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which
instruction is most important to include in this plan? (correct Answer- Avoid crowds for first two
months after surgery.
The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up is needed
for problems associated with chronic hypoxia? (correct Answer- ImageA client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns
to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of
30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which
intervention the nurse implement? (correct Answer- Assess compliance with routine prescriptions.
The RN is assigned to care for four surgical clients. After receiving report, which client should the
nurse see first? The client who is (correct Answer- Three days postoperative colon resection
receiving transfusion of packed RBCs.
The nurse is preparing an older client for discharge following cataract extraction. Which instruction
should be include in the discharge teaching? (correct Answer- Avoid straining at stool, bending, or
lifting heavy objects.
The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6
hours. The available 20 ml vial of potassium chloride is labeled, "10 mEq/5ml." how many ml of
potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is
required, round to the nearest tenth.) (correct Answer- 12.5
At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has
finally found a comfortable position. What action should the nurse take? (correct Answer- Place a
wedge under the client's right hip.
A client with a history of diabetes and coronary artery disease is admitted with shortness of breath,
anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with
audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5
ml/hour.
Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute
per infusion pump. With intervention should the nurse implement? (correct Answer- Titrate the
dopamine infusion to raise the BP.
The nurse ends the assessment of a client by performing a mental status exam. Which statement
correctly describes the purpose of the mental status exam? (correct Answer- Evaluate the client's
mood, cognition and orientation.
An older adult resident of a long-term care facility has a 5-year history of hypertension. The client
has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently
142/89. Which interventions should the nurse implement? (Select all that apply) (correct AnswerAdminister a daily dose of lisinopril as scheduled.
Provide a PRN dose of acetaminophen for headache [Show Less]