FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 A. Tell the client to keep her belongings because she will need them at discharge B.
... [Show More] Ask the client if she has had any recent thoughts of harming herself C. Reassure the client that the antidepressant drugs are apparently effective D. Support the client by telling her what wonderful progress she is making. 92. In assisting a client perform pursed lip breathing, the nurse should ensure that the client performs which action? A. Inhale through the nose with the mouth closed and exhale through pursed lips B. Inhale through pursed lips then exhale with the mouth held open C. Inhale through pursed lips and then exhale through the nose with the mouth closed D. Inhale through the mouth puff the cheeks and exhale through pursed lips 93. A 3 year-old admitted with fever of unknown origin (FUO) has begun vomiting in the past half hour. The child's temperature is 101.80 F, and the last dose of antipyretic medication was given 5 hours ago. The child has prescriptions of acetaminophen (Tylenol) 160 MG per 5 mL elixir or 160 mg suppositories PRN fever or pain. What action should the nurse take at this time? A. Make the child NPO and hold all medications untill the vomiting has stopped B. Give acetaminophen elixir to ensure the child's cooperation with swallowing C. Notify the healthcare provider that the child's fever has become dangerously high D. Use an acetaminophen suppository for the fever since the child is vomiting 94. A client is having Radical Masectomy. What is the position of choice during the immediate postoperative period? A. Side-lying on the operative side with the bed flat B. Supine with the arm on the operative side in a dependent position C. Semi-Fowler's position with the arm on the operative side elevated D. Sim's position with the arm on the operative side in a dependent position pg. 51 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 95. The nurse assesses the perineum of a client 12 hours after a normal vaginal delivery and finds that she has Perineal Hematomas. The nurse should prepare for which treatment? A. Heat lamp three times per day B. Insertion of vaginal packing C. Cold packs to the perineum D. Operative excision of the hematomas 96. A client at 28 weeks gestation is admitted to the antepartum unit and is being treated for preterm labor. She has a prescription for brethine (Terbutaline) 250 micrograms subcutaneously q4h. The medication is available for injection in 1 mg per ML vials. How many mL should the nurse administer? A. 0.025 B. 0.0025 C. 0.25 D. 25.0 97. A school-aged child with AIDS is exposed to an active case of Varicella. The nurse should recommend that the family take which action? A. Obtain penicillin G 1000U weekly B. Obtain the varicella vaccine C. Enroll in a home school program D. Obtain the varicella zoster immune globulin 98. The principle of client advocacy is best demonstrated when the nurse exhibits which behaviors on behalf of the client? A. Nurse who contacts child protective services to report a mother's decision to refuse vaccination for her firstborn infant B. Nurse refusing to care for a convicted rapist stating that personal discomfort would inhibit provision of quality of care C. Nurse who translates complaints for a Spanish-speaking client to the healthcare provider during rounds D. Nurse sharing information about life after death with a grieving family who just lost a loved one 99. The nurse is preparing a client for an Intravenous Pyelogram (IVP) scheduled for the following morning. What action is most important for the nurse to implement? A. Determine if the client has any allergies to shellfish B. Inform client that an IV dye will be administered before the IVP C. Explain that dizziness may occur when the dye is given D. Administer a bowel prep the evening before the procedure pg. 52 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 100. A nurse refuses to perform a procedure because it is beyond the scope of practice for practical nurses. Which resource best defines the nurse's legal responsibility in regard to scope of practice? A. Nursing practice standards for Licensed Practical/Vocational Nurses B. State Nurse Practice Act C. Code of Ethics for Licensed Practical/Vocational Nurses D. Patients Bill of Rights 101. While making the bed of a female client who is sitting in the bedside chair, the nurse observes the client seem anxious. To encourage verbalization by the client, what action should the nurse take? A. Continue to make the bed while conversing with the client B. Sit next to the client at a slight angle to continue the conversation C. Remain standing close enough to the client to hold her hand D. Bring a chair face-to-face with the client for further discussion 102. A client is admitted for observation after experiencing a Transient Ischemic Attack (TIA). The nurse anticipates implementing care for which client problem? A. High risk for injury B. Altered breathing patterns C. Ineffective airway clearance D. High risk infection 103. An elderly postoperative client has the Nursing diagnosis, "Impaired mobility related to fear of falling." Which desired outcome best directs Nursing actions for this client? A. The physical therapist will instruct the client in the use of a walker B. The nurse will place a gait belt on the client prior to ambulation C. The client will ambulate with assistance q4h D. The client will use self-affirmation statements to decrease fear 104. A female client complains to the nurse about being admitted to a semi-private room and expresses her displeasure because she requested a private room prior to admission. What response is best for the nurse to provide this client? A. Room assignments are based on client's acuity level, not necessarily by request B. I will place your name on the room request list for the next available private room pg. 53 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 C. Your healthcare provider must provide a written request to get you a private room D. There are no private rooms available, so you will have to stay here for the time being. 105. During preoperative preparation, the nurse should offer the client which explanation about why deep breathing exercising with an incentive spirometer are necessary after surgery? A. "Deep breathing exercises using spirometer will help prevent postoperative complications." B. "failure to keep your lungs working may result in pneumonia and death." C. "Incentive spirometry is uncomfortable but necessary for your postoperative care." D. "You will use the spirometer for the first postoperative day only." 106. The nurse is caring for a client who had a total Laryngectomy, Left Radical Neck Dissection, and tracheostomy. The client is receiving Nasogastric (NG) tube feedings via an enteral pump. Today the rate of the feeding was increased from 50mL/hr to 75mL/hr. What parameter should the nurse evaluate the client's tolerance to the rate of feeding? A. Bowel sounds B. Urinary and stool outputs C. Gastric residual volumes D. Daily weight 107. A client is admitted with a fever of undermined origin (FUO). During rounds, the nurse finds the client diaphoretic, and the linens are damp. What should the nurse do first? A. Change the bed linen to prevent chilling B. Check the client's vital signs and pain scale C. Assess the client for urinary incontinence D. Determine fluid intake for the past 8 hours 108. Which client should the nurse assign to an unlicensed assistive personnel (UAP)? A. An older male client with melena who is complaining of abdominal pain and needs a guaic test of a stool sample B. A young adult experiencing flank pain and hematuria who needs all urine strained for stones C. A client who has regular heart rate and after a pacemaker replacement now needs to ambulate D. An elderly client with Right-Sided Hemiplegia and Receptive Aphasia who needs to be transfered to the wheelchair pg. 54 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 109. The nurse is administering the shingles vaccine to an older maleclient who asks why he should receive the immunization. Which information should the nurse provide? A. A history of chickenpox indicates that the harbors the dormant virus B. The client's last dose of adult immunizations was 10 years ago C. A recent outbreak of fever blisters indicates reactivation of the virus D. Multiple stressful personal experiences increase his risk of shingles 110. In preparing a client for a lumbar puncture, what action should the nurse implement? A. Assist the client to the bathroom to void B. Apply a pulse oximeter to the client's finger C. Teach the client to cough and deep breathing exercises D. Ensure that the client has been NPO for six hours. 111. A client who had a lobectomy two days ago has 2 chest tubes, each attached to a water-sealed drainage system, Pleur-Evac. The nurse observes that in the last 8 hours the serosanguineous fluid has diminished to output in the drainage chamber. What is the most likely outcome of this observation? A. Removal of the lower chest tube, if a chest x-ray reveals no pleural accumulations B. Change the Pleur-Evac system and re-assess output in the empty chamber C. An increase in the prescribed suction force to facilitate-drainage of serosanguineous fluids D. Advance the chest tube to ensure proper placement of the tip to enhance drainage 112. While caring for a client who has been vomiting, the nurse notes that the client's breath has developed a fruity odor. What assessment should the nurse perform first? A. Auscultate the client's bowel sounds B. Determine the client's capillary glucose C. Observe the color of the client's urine D. Measure the client's oxygen saturation 113. The nurse is preparing to assist an elderly client to the bathroom. The nurse knows that an elderly adult's center of gravity changes from the hips to another area of the body. Which area of the body is the center of gravity for the elderly client? pg. 55 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 A. Upper torso B. Head C. Feet D. Upper extremities 114. A 60 year-old client with cancer of the liver is in Hepatic Coma and unresponsive. What should the nurse say to family members who are inquiring about the condition of their loved one? A. "Your loved one's condition is very critical, and there has been no response in the last 24 hours" B. "The nurses have not been able to arouse the client and the healthcare provider knows the outcome." C. "You need to discuss the condition with the charge nurse in a family conference." D. "The client's condition is extremely critical. Has your family made funeral arrangements?" 115. A client complains of kidney pain. The nurse understands that the kidneys are located where? A. On the retroperitoneal posterior abdominal wall at the costovertebral angle B. Within the curve of the duodenum, posterior to the spleen C. Lateral to the stomach in the hypochondriac region D. Superior aspect of the bladder in right and left iliac region 116. The nurse receives report on an adult client who has a central intravenous (IV) infusion. Where should the nurse observe when assessing the integrity of the access site? A. Umbilical area of the abdomen B. Antecubital fossae of the arm C. Chest wall below the clavicle D. Dorsal surface of the hand 117. The healthcare provider prescribes an IV solution of clindamycin (Cleocin) 850mg in 75 mL of D2W to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numeric value only. if rounding is required round to the nearest whole number) 75mL X 15gtt/mL = 38 38 118. The nurse is administering a subcutaneous injection of epoetin (Epogen) to a client with Chronic Kidney Disease (CKD). This medication is being administered to treat which manifestation of CKD? A. Anemia B. Anuria pg. 56 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 C. Hypotension D. Edema 119. The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. Prior to administering medications to this resident, what is the best Nursing action? A. Confirm the room and bed numbers with those on the medication record B. Ask a regular staff member to confirm the residents identity C. Hold the medication untill a family member arrives D. Re-orient the resident to name, place and situation. 120. The nurse is assessing an older male client with Gastritis. He has been unable to eat for the past 48 hours and has been vomiting during this same period of time. Which finding can the nurse expect this client to exhibit? A. Edemetous lower extremities and an increased temperature B. A decreased temperature and increased blood pressure C. Dry skin and an increased heart rate D. Diaphoresis and hypertension 121. An adult male client tells the nurse that he believes someone is trying to obtain his computer records, which his wife reports are recreational in nature. The client insists that an elaborate alarm system needs to be installed in his home. The nurse knows that this client is exhibiting which signs or symptom? A. Delusions of persecution B. Ideas of reference C. Hallucinations D. Confabulation 122. The nurse enters a client's room to perform a sterile dressing change. The nurse observes that the client is "gurgling" on oral secretions and coughing. Which action should the nurse take first? A. Position the client supine B. Finger sweep the oral cavity C. Perform oral suctioning D. Provide mouth care pg. 57 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 123. What length of blood pressure cuff should be the nurse use when obtaining a client's blood pressure? A. A cuff that is no longer than the circumference of the extremity should be used B. The length of the blood pressure cuff does not make a difference C. The cuff and its bladder should be nearly encircled in the extremity's circumference D. At least two-thirds the circumference of the extremity should be covered 124. A nurse is assisting a client from the bathroom back to bed following a minor surgical procedure. The client, still not fully alert, reports feeling nauseated and begins to vomit. What is the first action the nurse should take? A. Place a cool rag on the client's head B. Suction the client's oral cavity C. Provide the client an emesis basin D. Place the client in a side-laying position 125. The nurse is caring for a 10-year-old child with hemophilia who has recently been diagnosed as HIV positive. What precautions should the nurst take when interacting with the child and mother? A. No special precautions are needed B. Wear gloves only C. Wear gloves and a mask D. Wear a mask, gloves and gown. 126. A 26 year-old primigravida who delivered a 7-pound male infant 26 hours ago tells the nurse that she is confused about when she and her husband can return to having sexual intercourse. What info should the nurse reinforce with this client? A. They can have intercourse when the episiotomy is healed and the lochial flow has stopped B. They should wait to resume sexual activities until the fatigue assorted with a new baby has passed C. They can resume sexual activity at 6 weeks postpartum D. It is best to wait until both parties feel up to having sexual intercourse 127. The healthcare provider tells the family of a 6-year old child with a malignant brain tumor that the tumor is metastasizing and the child's condition is terminal. How can the nurse best help the family cope with this news? A. Refer the family to a support group to find answers to their questions pg. 58 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 B. Reinforce the stages of the grieving process C. Listen to the family's reactions and reflect and their fears and concerns D. Transfer the child to a private room 128. The nurse is implementing the plan of care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A. Describes being very depressed B. Has little appetite and neglects personal hygiene C. Is not interested in the activities of family and friends D. Begins to show signs of improvement 129. On a short-staffed unit a long-term care facility, it is important that the nurse assign the unlicensed assistive personnel (UAP) to complete morning care for the resident with which problem first? A. Dyspnea who uses oxygen continously B. Straight catheterization to be performed q6h C. Frequent episidoes of fecal incontinence D. Bolus feeding via PEG tube to be performed q4h 130. The nurse assess a client receiving a hypertonic full strength tube feeding that is infusing continous at 50 mL/hr. Which finding is most important for the nurse to reprot to the charge nurse? A. Dry mucous membranes B. Gastric residual of 50 mL C. Report of increased hunger D. Hyperactive bowel sounds 131. A male client who was admitted with Gangrene of the right lower extremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next? A. Explain the consequences of Sepsis if the amputation is delayed B. Notify the RN that the client's wife needs further explanation about the procedure C. Document on the client's record the refusal for surgical treatment D. Enourage the client's wife to express concerns about making the decision 132. A male client attends a community support program for mentally impaired and chemically abusive clients. The client tells the nurse that his drug of choice are cocaine and heroin. What is the greatest health risk for this client? A. Hepatitis pg. 59 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 B. Hypertention C. Diabetes D. Glaucoma 133. A male client who was admitted with Gangrene of the right lower extremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next? A. Explain the consequences of Sepsis if the amputation is delayed B. Notify the RN that the client's wife needs further explanation about the procedure C. Document on the client record the refusal for surgical treatement D. Encourage the client's wife to express concerns about making the decision 134. The nurse is caring for a group of clients on a postpartum unit. After shift report, which client should the nurse assess first? A. Gravida 6 Para 5 who delivered vaginally 24 hours ago B. Gravida 1 Para 0 who is not having contractions C. Gravida 3 Para 3 who delivered vaginally 2 hours ago D. Gravide 1 Para 2 who is preparing for discharge 135. A client returns to the unit following a cardiac catheterization with a Femoral artery Access. Which objective criteria is most important for the nurse to obtain immediately upon the clients return? A. Pupil responses to light B. Pedal pulses C. Respiratory rate D. Peripheral mobility 136. An elderly female client tells the nurse that she does not do regular Breast Self Examinations (BSE) because she is too old. The nurse's response to the client is based on what information? A. The incidence of breast cancer increases with age B. The client should have a health care provider do a breast exam at least once a year C. After age 70, breast cancer is less likely to occur D. The history of breast cancer in a family member is indicative of the need for BSE 137. A client with Meningitis is in a coma and Nursing care includes seizure precautions. To help prevent seizure activity, what interventions should the nurse implement? A. Maintain an oral airway suction equpment and oxygen at the bedside pg. 60 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 B. Provide respiratory isolation precautions for visitors and staff C. Provide emergency anti convulsant medication at the bedside D. Maintain a quiet calm darkened enviornment 138. The nurse is assisting a female client to obtain a voided specimen for urine culture. After the client cleanses the meatus, which intervention is performed next? A. Initiate the urine stream B. Seperate the labia C. Position the collection cup D. Observe the urine 139. A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the nurse identifies that an unlicensed assistive personel (UAP) has omitted a vital component of the protocol. After implementing the missing component, what should action should the nurse take? A. Report the UAP's omission to the charge nurse B. Complete an unusual occurence report C. Supervise the UAP after reviewing the protocol D. Assign the UAP to more stable clients the next day 140. What is the best intervention for the nurse to implement when providing morning care for an ambulatory client with an indwelling catheter (Foley)? A. Keep the catheter intact while assisting the client with a shower B. Remove the catheter while the client takes a shower C. Provide the client with a sponge bath in a chair or the bed D. Assist the client with a tub with the catheter clamped 141. Based on the Nursing diagnosis of, "Risk for Infection," which intervention should the nurse implement when providing care for an elderly client with Urinary incontinence? A. Maintain standard precautions B. Utilize an antibacterial perineal wash C. Insert an indwelling urinary catheter D. Initiate contact isolation precautions 142. The charge nurse brings a #18fr urinary catheter (Foley) with a 30 mL balloon to the nurse who is preparing to insert a catheter in a female client who weighs 50 kg. What action should the nurse take first? A. Ask the client if she has previously been catheterized pg. 61 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 B. Position the client and observe the urinary meatus C. Obtain a 30 ml syringe and a vial of sterile water D. Consult with the charge nurse about the catheter 143. An 82-year old client is admitted to the hospital with a fractured right hip. Following surgical repair, a footboard is placed at the client's feet. What is the reason the nurse will offer concerning the footboard? The footboard is used to... A. Prevent foot drop B. Prevent hip dislocation C. Promote moving in bed D. Promote early ambulation 144. Following a left leg above the knee amputation (AKA), a client voices several complaints. Which statement should be reported to the charge nurse immediately? A. My left foot is so painful B. My incision is so dry C. I've been feeling so light headed D. I'm tired of turning so much 145. In caring for a client following a below the knee amputation (BKA) which task is best for the nurse to delegate to the unlicensed assistive personnel (UAP) who is assisting with the care of this client? A. Empty and measure the drainage in the suction drainage device B. Reassure the client that phantom limb pain is genuine pain C. Review the client's vital signs for indications of infection D. Observe and mark the amount of drainage on the dressing 146. 2 days after an abdominal hysterectomy, an elderly client with diabetes Mellitus Type II has a syncopal episode. Her vital signs are within normal limites and her sugar is 325 mg/dL. what intervention should the nurse implement first? A. Give the client 4 ounces of orange juice B. Administer next scheduled dose of metformin (Glucophage) C. Cancel the clients dinner tray D. Administer regular insulin per sliding scale 147. A client returns to the postoperative unit following an open reduction and internal fixation of a hip fracture. The practical nurse applies the prescribed sequential compression devise (SCD) to both pg. 62 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 lower extremities. (BLE). What action is important when turning the client to a lateral position? A. Decrease the amount of pressure exerted on both legs while turning the client B. Replace the SCD's with an antiembolic stockings while using an abduction pillow C. Remove both of the SCDs while the cient is turned to the lateral position D. Observe the SCDs continue to inflate and deflate when the client is turned 148. When the nurse asks a male client with Bipolar Disorder if he is going to group session, he responds, "there is no use in me going to that group because all they talk about is Schizophrenia, which doesn't apply to me." Which response is best for the nurse to provide this client? A. "Tell me what medications you are taking right now" B. "You are probably right. The group really does not apply to your condition." C. "It sounds to me like it may be better for you that you stay here" D. "Let's talk about what you may have in common with the other group members." 149. A client is admitted with a newly diagnosed case of active tuberculosis (TB). Which intervention should the nurse teach the client about controlling transmission of tuberculosis (TB)? A. Proper disposal of tissues when coughing B. Importance of an adequate diet C. Complication sof the disease D. Side effects of anti-tubercular medications 150. During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not rising. What action should the nurse take first? A. Reposition the head to ensure an open airway B. Inflate the lungs with more breaths and air pressure C. Finger sweet for a foreign body lodged in the oral cavity D. Reposition hands on chest continue compressions 151. After a change of shift report, the nurse makes rounds on a postoperative unit. Which client finding necessitates the immediate attention of the nurse? A. A client who is having bright red drainage from the rectum following a colonoscopy with a polyp removal pg. 63 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 B. A client who has pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy C. An older client whose blood pressure is 100/70 after receiving meperidine for pain related to a hip fracture D. A client who has brown green bile draining froma T-tube after a cholecystectomy for Cholelithiasis. 152. Augmentin (amoxicillin/clavulante) 500mg suspension is prescribed for an older adult client who has trouble swallowing . The suspension is available in 125mg/5mL solution. How many ml should the client receive? (enter the numberic value only) 500mg/125m X 5mL = 20mL 153. The nurse observes that there are secretions in the air vent lumen of client's double lumen Nasogastric tube (NGT). Which action should the nurse implement? A. Instill 20 mL of air into the second lumen B. Irrigate the primary lumen with 20 mL of saline C. Place the client in a high Fowler's position D. Turn the suction device to continous suction 154. Which pediatric client is most likely to experience a disturbed body image? A. A. 10-year-old with plantar warts B. B. 14-year-old with acne vulgaris C. C. 16-year-old with a perineal tinea infection D. D. 12-year-old with bacterial cellulitis 155. The first day after a cesarean section (C-Section), when being assisted to the bathroom for the first time, a primavera client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. What action should the nurse take? A. A. Insert an indwelling catheter to empty the bladder and contract the fundus B. B. Return the client to bed and maitain bed rest until the lochial flow slows C. C. Check fundal consistency and continue to monitor the lochial flow amount D. D. Massage the fundus and avoid direct pressure on the cesarean incision. 156. The nurse is emptying the bedpan of a client with a bleeding gastric ulcer. What type of stool can the nurse expect this client to have. A. A. Black tarry stool B. B. Coffee-ground stool pg. 64 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 C. C. Bright red bloody stool D. D. Clay-colored stool 157. Which structure of the tracheobronchial tree is the most likely to compromise air passage when the smooth muscle layer is affected? A. A. Secondary bronchi B. B. Bronchioles C. C. Segmental bronchi D. D. Alveolar ducsts 158. The nurse is administering routine medications to an assigned group of elderly clients at an extended care facility. Which physiological change commonly associated with aging, increases the elderly client's risk of having an adverse response to the medication? A. A. Decreased gastrointestinal motility B. B. Poor cognitive function C. C. Poor peripheral circulation D. D. Decreased mobility 159. A client with diabetes is admitted with a 1cm size ulcer on the left great toe. The nurse observes that the left foot has a dusky color. In planning the client's care, which intervention should the nurse implement first? A. A. Bathe the wound daily with soap and water B. B. Record the color and temperature of the leg C. C. Perform dorsal flexion and extension exercises D. D. Check the client's dorsalis pedis and posterior tibialis pulse point 160. An ambulatory client with an indwelling urinary catheter (Foley) is requesting to take a shower for the first time. What is the best intervention for the nurse to implement? A. A. Clamp the catheter and assist the client with a tub bath B. B. Keep the catheter intact and assist the client with a shower C. C. Encourage the client to do self-care and provide personal care products D. D. Assist the client with a sponge bath in a chair or the bed 161. The nurse overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. What is the best Nursing action? A. A. Approach the individuals involved and ask them to stop B. B. Write an incident report and submit it to the unit manager C. C. Tell the client of the UAPs concern for him D. D. Try not to listen to the conversation since it is confidential pg. 65 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 162. During the past 30 days an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of the daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the nurse take? A. A. Withhold any medications that may cause these side effects B. B. Motivate the client by offering favorite foods as a prize C. C. Ask the family members to visit more often to stimulate the client D. D. Record the findings and report the symptoms to the charge nurse 163. A client is receiving nitroglycerin sublingual tablets for angina. What response should the nurse expect the client to manifest in response to the administration of this drug during an acute anginal episode? A. A. Pulse oximetry within normal limits B. B. Cessation of acute chest pain C. C. Hypertension and headache D. D. Premature ventricular contractions (PVC) 164. After a client returns from Hemodialysis, the nurse measures the client's weight and notes a 3-pound weight loss from the pre-dialysis weight. The client reports feeling weak and fatigued. What action should the nurse take next? A. A. Measure the client's blood pressure B. B. Auscultate the client's breath sounds C. C. Observe the client's legs for edema D. D. Determine the client's blood glucose 165. When providing oral care to an unconscious client who is a mouth breather and does not swallow, which action is most important for the nurse to implement? A. A. Use an oral suction catheter in the buccal cavity B. B. Inspect the oral cavity using gloves fingers C. C. Perform oral cleansing with a sponge toothette D. D. Apply a petroleum based lubricant to the client's lips 166. Wrist restrains were applied to a client who was severely agitated and disoriented. In monitoring the client, who is now asleep, which finding should be reported to the charge nurse? A. A. Respiratory rate decreases from 22 to 16 per minute B. B. Radial pulse volume decreases from +3 to +1= C. C. Blood pressure decreases from 130/84 to 120/76 D. D. Apical pulse rate decreases from 94-84 per minute pg. 66 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 167. The nurse is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, "An increase in granulation tissue will develop within 2 weeks," which intervention should the nurse implement? A. A. Remove heel protector every two hours B. B. Irrigate wound with sterile normal saline C. C. Replace dry sterile dressings as needed D. D. Apply heat for 15 minutes three times daily 168. A client's chief complaint is being able to swallow only small bites of solid food and liquid's for the last 3 months. The nurse should assess the client for what additional information? A. A. History of alcohol and tobacco use B. B. Average daily consumption of hot beverages C. C. Past traumatic injury to the neck D. D. Daily dietary roughage intake 169. The care plan for a male client with amyotrophic lateral sclerosis includes the Nursing diagnosis, "Decisional conflict related to concerns about mechanical ventilation." When assigned to care for this client, what intervention should the nurse implement based on this diagnosis ? A. A. Provide an opportunity for the client to meet with survivors of the disease who have undergone mechanical ventilation B. B. Remind the client that a mechanical ventilator is usually only needed for a short period of time C. C. Ask the hospice nurse to visit with the client to discuss his options for care if he chooses not to undergo mechanical ventilation D. D. Encourage the client to discuss his feelings and concerns related to the use of mechanical ventilation 170. What is the function of neutrophils? A. A. Heparin secretion B. B. Transport oxygen C. C. Phagocytotic action D. D. Antibody formation 171. Which membrane lines the abdominal cavity A. A. Perineum B. B. Pericardium pg. 67 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 C. C. Pleura D. D. Peritoneum 172. A man who was brought to the psychiatric hospital by the sheriff because he was hallucinating and stumbling on a downtown street, refuses to wait for a psychiatric evaluation. Which action should the nurse take? A. A. Tell the man when the elevator will see him B. B. Alert the staff to monitor exits to prevent escape C. C. Warn the client that he is likely to have a seizure D. D. Offer a hot meal a clean bed and a sleeping pill 173. The nurse is assessing care for residents on a 12-bed unit in an extended care facility. The staff consists of 1 unlicensed assistive personnel (UAP) and 1 certified medication aide. Which task should the nurse perform? A. A. Ambulate the client who has left hemiplegia and uses a cane B. B. Administer medications and formula to a client with a gastronomy tube C. C. Change a hydrocolloid dressing for a client with a stage II pressure ulcer D. D. Provide self-catheterization equipment for a client with paraplegia 174. The nurse is reviewing the discharge medication instructions with a client for disulfiram 10mg (Antabuse). Which instruction should the PN reinforce with the client? A. A. Avoid all sources of alcohol while taking this drug including cough syrups B. B. The medication should be taken at the same time each day C. C. Stop the drug if nausea, vomiting and/or prostration occur D. D. Have weekly blood tests to determine therapeutic drug levels and serum sodium 175. The nurse is preparing a client for a bone marrow aspiration. Which erythropoietic site is most likely to be used to obtain the specimen? A. A. Vertebrae B. B. Ribs C. C. Cranial bones D. D. Iliac crest 176. A male client admitted the morning of his scheduled surgery tells the nurse that he drank a glass of water during the night. What intervention will the nurse implement first? A. A. Auscultate the client for bowel sounds and ability to urinate B. B. Determine the amount of water and exact time it was taken pg. 68 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 C. C. Notify the healthcare provider of the client's fluid intake D. D. Reassure the client that a small amount of water is not harmful 177. The nurse is providing care for a client receiving an intravenous antibiotic to treat an infection. Which assessment findings require the most immediate action by the RN? A. A. Warm skin with elastic turgor B. B. Dry mouth with thirst C. C. Low grade fever with diaphoresis D. D. Hives with pruritus 178. The nurse should perform oral suctioning for a client with what problem? A. A. Atelactasis B. B. Dysphasia C. C. Gastric reflux D. D. Dysphagia 179. An elderly client at an adult daycare center with Type2 Diabetes Mellitus becomes unresponsive verbally and then tells the nurse, "I just don't feel right" Which initial action should the nurse take? A. A. Assess temperature B. B. Evaluate deep tendon reflexes C. C. Give 4 ounces of apple juice D. D. Administer glucagon 0.5mg IM 180. A 75-year-old male client with Alzheimer's Disease (AD) is admitted to an extended care facility. What intervention should the nurse include into his client's Nursing care plan? A. A. Describe the activities available to the residents and encourage him to choose the ones he prefers B. B. Introduce the client to the Nursing staff and the residents as soon as possible C. C. Plan to have the same Nursing staff provide care for the client whenever possible D. D. Encourage the client to remain on the unit for 3 weeks until he is oriented to his new surroundings 181. A newborn infant with a tracheoesophageal repair is receiving Gastrostomy (GT) feedings postoperatively. What intervention should the nurse implement during the GT feedings? A. A. Offer a pacifier during the feedings to satiate the sucking reflex associated with feedings pg. 69 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 B. B. Flush the GT with 50mL of water and clamp the GT to prevent leakage C. C. Place the infant in the right lateral position to facilitate gastric emptying D. D. Burp the infant after each 10mL of formula administration and re-feed any volume that is spit up 182. Which intervention is within the scope of practice for a nurse? A. A. Demonstrating deep breathing and coughing to postoperative client B. B. Teaching the use of glucometer to a newly diagnosed diabetic client C. C. Presenting support options that are available to those with cancer D. D. Discharge teaching about newly prescribed medications 183. The nurse is preparing a client for a mammogram. What instructions should the nurse provide the client? A. A. Do not exercise the upper body on the day of the procedure B. B. Avoid taking aspirin for one week prior to the procedure C. C. Avoid eating or drinking 6 hours prior to the procedure D. D. Do not use underarm deodorant on the day of the procedure 184. An older client is transferred to the rehabilitation unit with the diagnosis of Cerebrovascular Accident (CVA) with left sided hemiplegia. The nurse addresses the client from the right side, and the client points to the left leg and states, "There is a leg in my bed!" What is the best response by the nurse? A. A. "Your stroke has impaired your ability to recognize your paralyzed leg." B. B. "Look at your legs and you will see that they both belong to you." C. C. "Please explain to me what you thing happened to your leg." D. D. "I know you think there is an extra leg in your bed, but I do not see it." 185. Which technique should the nurse use to give a Z-track intramuscular injection? A. A. Ensure that no air is present in the syringe B. B. Inject the medication into the dorsal gluteal site C. C. Select a 22-gauge, 1 inch needle for injection D. D. Massage the site for 2 minutes after the injection pg. 70 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 186. The nurse observe that the IV catheter is no longer in a client's arm. It is on the bed, and the sheets are moist with IV fluid. The client is disoriented and states he does not remember pulling the catheter out. How should the nurse document this situations? A. A. Client does not remember pulling out the IV B. B. IV catheter found lying on bed sheets C. C. IV catheter pulled out by disoriented client D. D. IV discontinued and wet sheets changed 187. The nurse identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the nurse? A. A. Heart rate increases of 10 beats per minute B. B. Bowel movements decrease to 1 every third day C. C. Urinary output decreases of 250mL in the last 24 hours D. D. D. Systolic blood pressure decrease of 10mmHg 188. A nurse sees a colleague taking drugs from the hospital unit. What action should the nurse take? A. A. Report the incident to the person in charge of the unit or Nursing supervisor B. B. Notify the hospital security staff to retrieve the drugs from the colleague C. C. Report the colleague to the peer review committee of the hospital D. D. Confront the colleague and tell him/her to take the drugs back to the unit 189. Which term describes 2 or more tissues that compose a structure and perform a specific function? A. A. Elastic tissue B. B. Organ C. C. System D. D. Serous membrane 190. How many mL should the nurse document when calculating a client's 8-hour fluid intake? (Enter the numeric value only.) 0730 - 4 ounces of orange juice, hardboiled egg, and toast 1130 - 1/2 cup of soup, one half sandwich, and 1/2 cup of apple juice 1300 - vomitus of 100 mL 1400 - voided 250 ml and consumed one 12-ounce can of soft drink (type your answer in the box below) 1oz = 30mL; so 4oz of orange juice X 30mL = 120mL of orange juice Then 1 cup = 240; so ½ cup is 120mL of soup and ½ cup of apple juice is 120mL of apple juice = 240mL total vomitus is output, not intake, so ignore pg. 71 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 voided is output, not intake, so ignore 1 oz = 30mL; so 12oz is 12oz X 30mL = 360mL add them all; 120mL + 240mL + 360mL = 720mL 720 191. A male client is receiving ferrous sulfate (iron), docusate sodium (Colace) and codeine. He reports that his last bowel movement was 3 days ago. During medication administration, which action should the nurse implement? A. A. Offer the client a full glass of water B. B. Give medications 2 hours apart C. C. Provide a snack with the medications D. D. Administer only the docusate sodium 192. The nurse is caring for a primagravida 5 hours after a vaginal delivery. Which finding should the nurse report immediately to the charge nurse? A. A. Pulse rate of 90 beats/minute B. B. Rubor lochia saturating 3 perineal pads per hour C. C. Complaints of perineal pain D. D. Firm fundus between umbilicus and the symphysis pubis 193. A client with recurrent urinary tract infections (UTI) is being discharged. What instruction is appropriate for the nurse to include in the discharge teaching plan? A. A. Drink 3 quarts of water daily B. B. Avoid swimming in public pools C. C. Avoid intercourse until all antibiotics have been taken D. D. Drink 3, 6-ounce cans of cranberry juice daily 194. Which criterion is best for the nurse to use when evaluating a client's response to an analgesic that was administered for postoperative pain? A. A. Amount of medication required to relieve pain B. B. Activity without guarding or grimacing C. C. Objective parameters of blood pressure and respirations D. D. Subjective score on a 1 to 10 pain scale 195. A client is diagnosed with Pericarditis after a Myocardial Infarction (MI) and asks the nurse, "Why did this happen?" What explanation should the nurse offer? pg. 72 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 A. A. The sac surrounding the heart has become inflamed from the cells damaged by the heart attack B. B. The space around your heart is filling with fluid and your healthcare provider will have to explain the treatment C. C. The heart cells have been infiltrated by organisms and a secondary autoimmune reaction has occurred D. D. This is an infection of the lining of the heart caused by bacteria entering through your gums 196. In describing the "at risk" individual for developing Breast Cancer, the nurse should recognize that which client is at the highest risk? The woman who is... A. A. a 40-year-old African American with Hypertension (HTN) B. B. a 35-year-old with trauma to the breast C. C. a 32-year-old whose mother had breast cancer D. D. a 50-year-old Caucasian who has never had a mammogram 197. What technique should the nurse use to administer a medicated ophthalmic ointment? A. A. Massage the lashes with the excess ointment that is squeezed out when shutting the lids B. B. Place a thin ribbon of ointment into the lower conjunctival sac from the inner to outer canthus C. C. Pull both upper and lower lids apart to drop the ointment onto the anterior surface of the eye D. D. Wear gloves when placing the tip of the ointment tube in the center of the lower lid 198. A client is using an incentive spirometer on the first postoperative day after an inguinal Herniorrghaphy. The nurse should re-teach the proper use of the spirometer when the client demonstrates what action? A. A. Using a tight seal around the mouth piece B. B. Exhaling slowly after two seconds C. C. Blowing forcefully into the mouthpiece D. D. Sitting upright during treatment 199. An 8-year-old recovering from a Celiac Crisis requests a bowl of cereal for breakfast. Which cereal should the nurse provide? A. A. Corn flakes B. B. Granola C. C. Oatmeal pg. 73 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 D. D. Wheat puffs E. E. Rice 200. The nurse assumes care of a client who was admitted earlier in the day for a scheduled Hysterectomy in the morning. Which recorded assessment data obtained by the admitting registered nurse is objective? (Select all that apply). A. A. Anemia B. B. Menorrhagia C. C. Tiredness D. D. Orthostatic hypotension E. E. Fear F. F. Nervousness 201. The nurse empties a large amount of serous drainage from a postoperative client's Hemovac drain. In what order should the nurse implement these procedures? (Place the first action on top and the last action on the bottom.) A. Compress drain... close drain... discard drain... document 202. The nurse should recommend that males over the age of 45 obtain which test to screen for prostatic cancer? A. A. Prostate-specific antigen (PSA) B. B. Alpha-fetoprotein radio immunoassay (AFP) C. C. Ultrasound of the scrotum D. D. Serum testosterone level 203. The nurse is giving medications to a client who was admitted to the hospital with a diagnosis of Diabetes Mellitus Type II. After checking the finger stick glucose at 1630dL, what dose of insulin should the nurse administer? (enter the numeric value only) (Click on each chart tab for additional information. Please be sure to scroll to the bottomright corner of each tab to view all information contained in the client's medical record.) 8 204. A client is receiving 0.5 grams of a prescription medication that is dispensed as 500 mg/5mL. How many ml should the PN administer? (enter the numeric value only. If rounding is required, round to the nearest tenth.) 5 pg. 74 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 205. The nurse is receiving a client following an emergency Cesarean Section (C-Section). Which information is most important for the nurse to obtain? A. A. Blood pressure and pulse rate B. B. Gravida and parity C. C. Medications received during labor D. D. Temperature and respiratory rate 206. The nurse is preparing to insert an indwelling catheter for an 89- year-old client who has severe contractures of both lower extremities. The client cries in pain when positioned supine while the nurse attempts to abduct the hips to visualize the perineum. What action should the nurse take? A. A. Report to the charge nurse that the client cannot cooperate for the insertion B. B. Recruit two UAPs to hold the legs apart while the catheter is inserted C. C. Position laterally for posterior access in visualizing the meatus for insertion D. D. Pre-medicate the client with a narcotic analgesic to relax the skeletal muscles 207. An elderly client in the early postoperative period requires close monitoring due to aging and multisystem changes. The nurse monitors respirations and auscultates breath sounds frequently. What other intervention should the nurse implement related to the client's decreased vital capacity? A. A. Evaluate pulse oxygen saturation B. B. Allow extra education time C. C. Encourage high protein supplements D. D. Monitor intake and output 208. The nurse can also refer to the external ear as what other known name... A. A. Pinna B. B. Malleus C. C. Incus D. D. Cochlea pg. 75 FINAL “EXIT” HESI! Last day of Concorde LVN School – 04/16/2021 209. During immediate postoperative period, which condition has the highest priority when planning Nursing care? A. A. Infection B. B. Respiratory obstruction [Show Less]