HESI EXIT EXAM FINAL CAPSTONE 160 QUESTIONS (95.36 ĐIỂM)
1/ A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed
... [Show More] with
hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?
A. Instruct the mother to give the child sugar water only.
B. Offer the infant oral rehydration solution every 2 hours.
C. Provide Pedialyte feedings via the nasogastric tube.
D. Maintain intravenous fluid therapy per prescription.
2/ A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory
test results show that the client’s serum magnesium level has decreased below the normal range. In addition to
contacting the healthcare provider, what nursing action is most important?
A. Observe rhythm on telemetry monitor. (QL)
B. Check for visual difficulties.
C. Assess for hip and hand joint pain.
D. Note most recent hemoglobin level.
3/ The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to
contracting lead poisoning?
A. An 8-year-old who lives in a housing project.
B. A 2-year-old who plays on aging outdoor playground equipment. (QL)
C. An adolescent who works part time in a paint factory.
D. A 10-year-old who has Type 1 diabetes mellitus.
4/ The client provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye-opener)
questionnaire. Which interpretation should the nurse provide the client?
A. The CAGE questionnaire is a tool used to identify general substance abuse.
B. At least two positive responses are strongly suggestive of alcohol dependence.
C. One positive response indicates the client should seek help with alcohol addiction.
D. All responses to the CAGE questionnaire must be positive to suggest alcohol dependence.
5/ 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?
A. Evaluate closest proximal pulse. (QL)
B. Note amount and color of wound drainage.
C. Observe for swelling around the stump.
D. Assess skin elasticity of the stump.
6/ An adolescent with intellectual disability is admitted to the adolescent unit for repeatedly refusing to complete
oral hygiene. The healthcare provider prescribes for the client to brush the teeth three times a day. In the
psychiatric team conference, a behavior modification program is recommended to engage the client’s
participation. When implementing this technique, which reinforcement is best for the nurse to provide?
A. Unit tasks for each omission of teeth brushing.
B. Candy for each successful hygiene task, like brushing his teeth.
C. Privilege restriction or fines for refusing to complete a hygienic task.
D. Preferred activities or tokens for each compliance. (QL) [Show Less]