Hesi exit 5 - 160 Questions and Answers 2023-2024
Suicide precautions are initiated for a child admitted to the mental health unit following an
... [Show More] intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement? - Remove cigarettes for the client's room
A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.)
A.)A client must be willing to accept palliative care, not curative care.
B.)The healthcare provider must project that the client has 6 months or less to live.
C.)The client must be diagnosed with clinical depression
D.)The client must be of sound mind - A,B
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan? - Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? - Digoxin
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? - Supervise a newly hired graduate nurse during an admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take? - Ask the client what he is thinking about at his time.
After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
A.)Administer PRN nebulizer treatment.
B.)Obtain 12 lead electrocardiogram.
C.)Monitor continuous oxygen saturation.
D.) Lay the client in the prone position - A,B,C
The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take? - Administer a prescribed analgesia for pain.
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child? - Use sunblock or protective clothing when outdoors.
Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? SATA
Tell the client that its a mild reaction
B.)Notify the food services department of the allergy.
C.)Enter the allergy information in the client's record.
D.)Add egg allergy to the client's allergy arm band. - B,C,D
The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement? - Perform bilateral chest auscultation.
After administering an antipyretic medication. Which intervention should the nurse implement? - Encouraging liberal fluid intake
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? - Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider
After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? - Determine client's pulse, blood pressure, and respirations
The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply)
A.)Take postoperative vital signs for a client who has an epidual following knee arthroplasty
B.)Collect a sputum specimen for a client with a fever of unknown origin
C.)Ambulate a client who had a femoral-popliteal bypass graft yesterday - A,B,C
A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement? - Raise the head of the bed to a Fowler's position and support his arms with a pillow
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next? - Administer the analgesic as requested
The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.) - 12160
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?
A.)Observe aspiration site.
B.)Assess body temperature
C.)Monitor skin elasticity
D.)Measure urinary output - A
An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? - Reinforce the importance of annual papanicolaou (Pap) smears.
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first? - Establish a structured routine for the client to follow.
A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? - Ventricular arrhythmias. [Show Less]