HESI EXIT EXAM REVIEW LATEST 2024
ACTUAL EAXM COMPLETE 400
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY
GRADED
... [Show More] A+
1. The home health nurse visits an elderly female client who
had a brain attack three months ago and is now able to
ambulate with the assistance of a quad cane. Which
assessment finding has the greatest implications for this
client's care?
• The husband, who is the caregiver, begins to weep when the
nurse asks how he is doing.
• The client tells the nurse that she does not have much of an
appetite today.
• The nurse notes that there are numerous scatter rugs
throughout the house.
• The client's pulse rate is 10 beats higher than it was at the
last visit one week ago. - ...ANSWER...Ans 3 - The nurse
notes that there are numerous scatter rugs throughout the
house.
Rationale -
Scatter rugs (C) pose a safety hazard because the client can
trip on them when ambulating, so this finding has the greatest
significance in planning this client's care. Psychological
support of the caregiver (A) is a less acute need than that of
client safety. The nurse needs to obtain more information
about (B), but this is not a safety issue. (D) is not a significant
increase, and additional assessment might provide
information about the reason for the increase (anxiety,
exercise, etc.).
2. The nurse is digitally removing a fecal impaction for a
client. The nurse should stop the procedure and take
corrective action if which client reaction is noted?
• Temperature increases from 98.8° to 99.0° F.
• Pulse rate decreases from 78 to 52 beats/min. Correct
• Respiratory rate increases from 16 to 24 breaths/min.
• Blood pressure increases from 110/84 to 118/88
mm/Hg. -
...ANSWER...• Pulse rate decreases from 78 to 52
beats/min.
Rationale -
Parasympathetic reaction can occur as a result of digital
stimulation of the anal sphincter, which should be
stopped if
the client experiences a vagal response, such as bradycardia
(B). (A, C, and D) do not warrant stopping the procedure.
3. The nurse is providing passive range of motion (ROM)
exercises to the hip and knee for a client who is unconscious.
After supporting the client's knee with one hand, what
action
should the nurse take next?
• Raise the bed to a comfortable working level.
• Bend the client's knee.
• Move the knee toward the chest as far as it will go.
• Cradle the client's heel. Correct - ...ANSWER...•Ans -
Cradle the client's heel. Correct
RATIONALE: Passive ROM exercise for the hip and knee
is
provided by supporting the joints of the knee and ankle
(D)
and gently moving the limb in a slow smooth firm but
is moved toward the chest to the point of resistance (C)
two or three times.
4. A client who has moderate, persistent, chronic
neuropathic
pain due to diabetic neuropathy takes gabapentin
(Neurontin)
and ibuprofen (Motrin, Advil) daily. If Step 2 of the World
Health Organization (WHO) pain relief ladder is prescribed,
which drug protocol should be implemented?
• Continue gabapentin. Correct
• Discontinue ibuprofen.
• Add aspirin to the protocol.
RATIONALE: Add oral methadone to the protocol -
...ANSWER...Ans 1 - Continue gabapentin
Based on the WHO pain relief ladder, adjunct
medications,
such as gabapentin (Neurontin), an anti-seizure medication,
may be used at any step for anxiety and pain
management, so
(A) should be implemented. Non-opioid analgesics, such
as
ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and
3
include opioid narcotics (D), and to maintain freedom from
pain, drugs should be given around the clock rather than
by
the client s PRN requests.
5. The nurse is preparing to irrigate a client's indwelling
urinary catheter using an open technique. What action
should
the nurse take after applying gloves?
• Empty the client's urinary drainage bag.
• Draw up the irrigating solution into the syringe.
solution into the syringe (B). The syringe is then attached to
the catheter and the fluid instilled, using aseptic technique
(D). Once the irrigating solution is instilled, the client's
catheter should be secured to the drainage tubing (C). The
urinary drainage bag can be emptied (A) whenever intake and
output measurement is indicated, and the instilled irrigating
fluid can be subtracted from the output at that time.
6. Which client care requires the nurse to wear barrier gloves
as required by the protocol for Standard Precautions?
• Removing the empty food tray from a client with a urinary
catheter.
• Washing and combing the hair of a client with a fractured
leg in traction.
• Administering oral medications to a cooperative client with
a wound infection.
• Emptying the urinary catheter drainage bag for a client with
Alzheimer's disease. Correct - ...ANSWER...ANS - Emptying
the urinary catheter drainage bag for a client with Alzheimer's
disease.
Rationale -
possible contact with body secretions, excretions, or broken
skin is an indication for wearing barrier (nonsterile) gloves.
Emptying a urine drainage bag requires the use of gloves (D).
(A, B, and C) do not require gloves.
7. What action should the nurse implement to prevent the
formation of a sacral ulcer for a client who is immobile?
• Maintain in a lateral position using protective wrist and vest
devices.
• Position prone with a small pillow below the diaphragm. •
Raise the head and knee gatch when lying in a supine
position.
Transfer into a wheelchair close to the nurse's station for
observation - ...ANSWER...Ans - Position prone with a small
pillow below the diaphragm.
Rationale -
The prone position (B) using a small pillow below the
diaphragm maintains alignment and provides the best pressure
relief over the sacral bony prominence. Using protective
(restraining) devices (A) is not indicated. Raising the head and
bed gatch (C) may reduce shearing forces due to sliding down
in bed, but it interferes with venous return from the legs and
places pressure on the sacrum, predisposing to ulcer
formation. Sitting in a wheelchair (D) places the body weight
over the ischial tuberosities and predisposes to a potential
pressure point.
8. What intervention should the nurse include in the plan of
care for a client who is being treated with an Unna's paste
boot for leg ulcers due to chronic venous insufficiency?
• Check capillary refill of toes on lower extremity with Unna's
paste boot.
• Apply dressing to wound area before applying the Unna's
paste boot.
• Wrap the leg from the knee down towards the foot.
• Remove the Unna's paste boot q8h to assess wound healing.
- ...ANSWER...ANS - Check capillary refill of toes on lower
extremity with Unna's paste boot.
Rationale -
The Unna's paste boot becomes rigid after it dries, so it is
important to check distally for adequate circulation (A).
Kerlix is often wrapped around the outside of the boot and an
ace bandage may be used to cover both, but no bandage
should be put under it (B). The Unna's paste boot should be
applied from the foot and wrapped towards the knee (C). The
Unna's paste boot acts as a sterile dressing, and should
not be removed q8h. Weekly removal is reasonable (D).
9. The nurse is administering an intermittent infusion of
an
antibiotic to a client whose intravenous (IV) access is an
antecubital saline lock. After the nurse opens the roller
clamp
on the IV tubing, the alarm on the infusion pump
indicates an
obstruction. What action should the nurse take first?
• Check for a blood return.
• Reposition the client's arm. Correct
• Remove the IV site dressing.
• Flush the lock with saline. - ...ANSWER...ANS -
Reposition
the client's arm.
Rationale -
If the client's elbow is bent, the IV may be unable to
infuse,
resulting in an obstruction alarm, so the nurse should
first
attempt to reposition the client's arm to alleviate any
obstruction (B). After other sources of occlusion are
eliminated, the nurse may need to check for a blood
return
(A), remove the dressing (C), or flush the saline lock (D)
and
then resume the intermittent infusion.
10. A female client who has breast cancer with
metastasis to
the liver and spine is admitted with constant, severe pain
despite around-the-clock use of oxycodone (Percodan)
and
• Schedule and total dosages of drugs currently used for
breakthrough pain.
• Sympathetic responses consistent with onset of acute pain. -
...ANSWER...ANS - Sensory pattern, area, intensity, and
nature of the pain.
Rationale -
The components of every pain assessment should include [Show Less]