HESI EXIT COMPREHENSIVE REVIEW EXAM A QUESTION AND ANSWERS EXPLAINED
1. The nurse is correct in withholding an older adult client's dose of nifedipine if ... [Show More] which assessment finding is obtained?
2. Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP?
3. A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff?
4. When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as ebola and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse-manager to take?
5. The nurse is planning a community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program?
6. Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff?
7. A male client with Parkinson disease is prescribed the antiparkinsonian agent amantadine HCl. Which action should the nurse take?
8. A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain?
9. A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations?
10. Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention should the nurse implement based on these results?
11. A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client?
12. A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother?
13. Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with otitis externa?
14. Prior to administering an oral suspension, which intervention is most important for the nurse to implement?
15. On conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma?
16. Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse?
17. Which client is best to assign to a graduate PN who is being oriented to a renal unit?
18. A client has been receiving levofloxacin, 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement?
19. When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity?
20. A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide?
21. A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic?
22. The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP?
23. The nurse is preparing to administer dalteparin subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose?
24. Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma?
25. The charge nurse of a medical-surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time?
26. A male client is admitted for observation after being hit on the head with a baseball bat. Six hours after admission, the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on room air. Which intervention should the nurse perform first?
27. A five year old is in Bryant's traction for intervention for a fractured femur. Which finding by the nurse would require intervention?
28. The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN?
29. Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable?
30. The health care provider prescribes 1000 mL of Ringer's lactate solution with 30 units of oxytocin (Pitocin) to infuse over 4 hours for a client who has just delivered a 10-lb infant by cesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse should set the flow rate at how many gtt/min?
31. A comatose client is admitted to the critical care unit, and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids?
32. When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include?
33. The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented?
34. Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical treat-ments for dehydration in a 36-month-old child? (Select all that apply.)
35. The nurse should encourage a laboring client to begin pushing at which point?
36. The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment?
37. A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first?
38. Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)?
39. The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved?
40. A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide PO and 40 mg of furosemide PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level?
41. The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents?
42. A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit?
43. Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.)
44. The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a client who has had an appendectomy. The IV tubing being used delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is necessary, round to the nearest whole drop.)
45. The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members?
46.The antigout medication allopurinol is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse?
47.The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience?
48.After administration of a 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority?
49.Which assessment finding indicates that nystatin swish and swallow, prescribed for a client with oral candidiasis, has been effective?
50Two days after swallowing 30 tablets of alprazolam, a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.)
51.The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP?
52. The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide?
53. When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse-manager implement?
54. A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide?
55. The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of regular and NPH insulin. Which statement indicates that the client needs further instruction?
56. The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement?
57. A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation?
58. The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement?
59. The client with which fasting plasma glucose level needs the most immediate intervention by the nurse?
60. A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client's stress associated with repeated hospitalization?
61. A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client?
62. A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary?
63. A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client?
64.The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first?
65. An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of C. difficile. While planning care, which nursing goal should the nurse establish as the priority?
66.A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test?
67. A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next?
68. The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement?
69. A nurse is planning client care and wants to verify the steps for a specific client procedure. Which action should the nurse take?
70. A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make?
71. A client with hepatic failure tells the nurse about recent use of acetaminophen. How should the nurse respond to this client's statement?
72. Which physiologic finding in an older adult contributes to an adverse drug reaction?
73. Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)?
74. A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client?
75. An older client who resides in a long-term care facility is hearing-impaired. How should the nurse modify interventions for this client?
76. A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's hips are externally rotated. Which intervention is most important for the nurse to implement?
77. A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting?
78. A child is having a generalized tonic-clonic seizure. Which action should the nurse take?
79. A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications?
80. A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time?
81. The nurse is obtaining a client's sexual history. Which finding requires additional follow-up regarding the client's self-image?
82. A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement?
83. The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. Which action should the nurse perform?
84. According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults?
85. Upon assessing a newborn male, the nurse finds the urethral meatus opens on ventral side of penis behind the glans. The nurse would recognize this finding is consistent with which finding?
86. A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse?
87. The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN?
88. A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond?
89. The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indica-tion(s) best supports the client’s need for insertion of an indwelling urinary catheter? (Select all that apply.)
90. A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly?
91. What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.)
92. The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.)
93. The nurse calls the primary health care provider to report the status of a postsurgical client. Place the statements in the correct SBAR communication format.
94. The nurse administers levothyroxine to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.)
95. The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last.
96. The nurse recognizes which behaviors in a client as warning signs of an impending suicide attempt? (Select all that apply.)
97. Which nursing intervention(s) should be implemented when caring for a client with bipolar disorder in the manic phase? (Select all that apply.)
98. The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.)
99. A child with nephrotic syndrome is receiving prednisone. Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child?
100. Which findings would suggest to the nurse that diagnosis of glomerulonephritis is correct? [Show Less]