HESI EXIT EXAM NEWEST 2024 TEST
BANK updated with verified questions and
detailed answers with rationales (GRADED
A+)
The nurse is caring for a
... [Show More] client who had gastric bypass surgery yesterday. Which
intervention is most important for the nurse to implement during the first 24
postoperative hours?
a. Insert an indwelling urinary catheter
b. Monitor for the appearance of an incisional hernia
c. Instruct the client to eat small frequent meals
d. Measure hourly urinary output. - ANSWER-d. Measure hourly urinary output.
A client was admitted to the cardiac observation unit 2 hours ago complaining of chest
pain. On admission, the client's EKG showed bradycardia, ST depression, but no
ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the
nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves
and ST segment elevations in the anterior leads. What intervention should the nurse
perform?
a. Increase the peripheral IV flow rate to 175 ml/hr to prevent hypotension and shock
b. Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal
cannula.
c. Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzymes
levels.
d. Notify the healthcare provider of the client's increase chest pain a call for the
defibrillator crash cart. - ANSWER-b. Administer prescribed morphine sulfate IV and
provide oxygen at 2 L/min per nasal cannula.
Based on the information provided in this client's medical record during labor, which
should the nurse implement? (Click on each chart tab for additional information. Please
be sure to scroll to the bottom right corner of each tab to view all information contained
in the client's medical record.)
a. Apply oxygen 10 l/mask
b. Stop the oxytocin infusion
c. Turn the client to the right lateral position.
d. Continue to monitor the progress of labor. - ANSWER-d. Continue to monitor the
progress of labor.
The nurse is completing a head to be assessment for a client admitted for observation
after falling out of a tree. Which finding warrants immediate intervention by the nurse?
a. Sluggish pupillary response to light
b. Clear fluid leaking from the nose.
c. Complaint of severe headache
d. Periorbital ecchymosis of right eye. - ANSWER-b. Clear fluid leaking from the nose.
A nurse with 10 years experience working in the emergency room is reassigned to the
perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?
a. A client who is leaking clear fluid
b. A mother who just delivered a 9 pounds boy
c. A mother with an infected episiotomy.
d. A client at 28- weeks' gestation in pre-term labor. - ANSWER-c. A mother with an
infected episiotomy.
A client who received multiple antihypertensive medications experiences syncope due
to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to
hold the client's scheduled antihypertensive medication?
a. Increased urinary clearance of the multiple medications has produced diuresis and
lowered the blood pressure
b. The antagonistic interaction among the various blood pressure medications has
reduced their effectiveness
c. The additive effect of multiple medications has caused the blood pressure to drop too
low.
d. The synergistic effect of the multiple medications has resulted in drug toxicity and
resulting hypotension. - ANSWER-c. The additive effect of multiple medications has
caused the blood pressure to drop too low.
A female client has been taking a high dose of prednisone, a corticosteroid, for several
months. After stopping the medication abruptly, the client reports feeling "very tired".
Which nursing intervention is most important for the nurse to implement?
a. Measure vital signs
b. Auscultate breath sounds
c. Palpate the abdomen
d. Observe the skin for bruising - ANSWER-a. Measure vital signs [Show Less]