HESI EXIT RETAKE GUIDE- UPDATED REVIEW
1. An older male client is brought to the Emergency Department by family members who he has become increasingly
... [Show More] confused in the last 3 days. Which actions should the nurse (Select all That apply)
A. Explain that advanced age is associated with confusion
B. Evaluate polypharmacy for possible drug interactions
C. Obtain a urine specimen for culture and sensitivity
D. Discuss nursing home placement with the family
E. Determine oxygen saturation rate and breath sounds Correct Answer: B, C, E
2. A multigravida, full-term, laboring client complains of “back Labor”. Vaginalexamination reveals that the client’s 3cm with 50% effacement and the fetal head is at -1 station. What action should the nurse implement?
A. Apply counter-pressure to the sacral area
B. Turn the client to a lateral position
C. Notify the scrub nurse to prepare the OR
D. Ambulate the client between contractions Correct Answer: A
3. An infant born to a heroin-addicted mother is admitted to the neonatal care unit. What behaviors can this to exhibit?
A. Lethargy and a poor suck
B. Facial abnormalities and microcephaly
C. Irritability and a high-pitched cry
D. Low birth weight and intrauterine growth retardation Correct Answer: C
4. A client with gestational diabetes is undergoing a non-stress test (NST) at 34weeks gestation; the baby’s heart is 144 beats/minute. The client is instructed to mark the fetal monitor paper by pressing a…. Each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. ????
A. The mother perceives and marks at least four fetal movements
B. Fetal movements must be elicited with a vibroacoustic stimulator
C. Two FHR accelerations of 15 beats/minute x 15 seconds are recorded D. No FHR late decelerations occur in response to fetal movement
Correct Answer: C
5. A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive, the respiration rate of 60 breaths/minute, and a heart rate of 150 beats/minute. What action should the nurse first?
A. Obtain a pulse oximeter reading
B. Assess the Child’s blood pressure
C. Perform a neurological assessment
D. Initiate peripheral intravenous access
Correct Answer: A
6. An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse ….. Tachypneic, and hypotonic. What is the first action that the nurse should take?
A. Notify the healthcare provider immediately
B. Increase the temperature of the radiant warmer
C. Assess the infant’s heart rate
D. Determine the infant’s blood sugar level Correct Answer: D
7. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important at time the infusion rate is increased?
A. Contraction pattern
B. Blood pressure
C. Infusion site
D. Pain level
Correct Answer: A
8. A 6-year old child with acute infectious diarrhea is placed on rehydration therapy regimen. Which action should the nurse instruct the parent to take if the child begins to vomit?
A. Continue giving ORS frequently in small amounts
B. Withhold all oral intake
C. Supplement ORS with gelatin or chicken broth
D. Provide only bottled water Correct Answer: A
9. Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. Which is the first nurse priority?
A. Clean the perineal area to prevent infection
B. Assess the mother’s blood pressure to check for signs of preeclampsia
C. Assess the mother’s temperature to check for development of sepsis
D. Have a meconium aspirator available at delivery Correct Answer: D
10. During a 26-week gestation prenatal exam, a client reports occasional dizziness. What intervention is best for the nurse to recommend to this client?
A. Elevate the head with two pillows while sleeping
B. Lie on the left or right side when sleeping or resting
C. Increase intake of foods that are high in iron
D. Decrease the amount of carbohydrates in the diet
Correct Answer: B
11. A postpartal client complains that she has the urge to urinate every hour but is only able to a small….
What intervention provides the nurse with the most useful information?
A. Initiate a perineal pad count
B. Catheterize for residual urine after next voiding
C. Assess for a perineal hematoma
D. Determine the client’s usual voiding pattern Correct Answer: B
12. A client is scheduled for a laminectomy to treat lower back pain related to a herniated intervertebral disk. When conducting preoperative teaching, the nurse should teach the client that numbness and tingling in the lower extremities sometimes occurs postoperatively as the result of which condition?
A. Effects of intrathecal anesthesia that resolve quickly
B. Minor injuries caused by positioning during surgery
C. Pressure on the nerves due to prolonged immobility
D. Manipulation of nerves and muscles during surgery Correct Answer: D
13. The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child’s diagnosis?
A. “I couldn’t get my son’s socks and shoes on this morning”
B. “I couldn’t get my son to calm down and sleep last night”
C. “My son has had a red rash over his entire body for the past 4 days” D. “My son has been on Augmentin for 2 days for an ear infection” Correct Answer: A
14. The nurse is evaluating the home care teaching of a family who has a child with cystic fibrosis. Which parental action indicates correct understanding of the child’s home care?
A. Performs postural drainage after meals
B. Supplements diet with water-soluble vitamins and fluids
C. Plans a diet high in fat and calories
D. Gives pancreatic enzymes before every meal and snack Correct Answer: D
15. Client with mitral stenosis is at 28-weeks gestation. In assessing this client, which observation should the nurse investigate first?
A. Edematous feet
B. Persistent cough
C. Increased fatigue
D. Recent sadness
Correct Answer: B
16. A 72-year-old client is admitted to the hospital after falling at home. In taking a nursing history, the nurse notes that the client is taking labetalol HCL (Normodyne) 300mg PO BID and ranitidine (Zantac) 150 mg PO QID. What nursing intervention is most important to include in this client’s nursing care plan?
A. Determine gastric pH on admission
B. Weigh daily in early morning
C. Frequent monitoring of blood pressure
D. Daily assessment of WBCs and platelets Correct Answer: C
17. Captopril (Capoten) is prescribed for an infant admitted 3 days ago with a diagnosis of heart failure. During assessment, which clinical finding indicates to the nurse that the medication is effective?
A. Capillary refill is down from 4 seconds on admission to 2 seconds
B. Blood pressure decrease from 125/85 on admission to 106/60
C. Heart rate decreased from 200 beats/minute on admission to 140 beats/minute
today
D. Periorbital adema disappears Correct Answer: B
18. The client with paranoia and homicidal ideation is brought to Emergency Department…. The client states that her daughter lives her television set and will come the nurse talk to her. What additional finding indicates that the client has a thought disorder?
A. Feels lonely and isolated
B. Feels very anxious
C. Easily changes the subject
D. Stays in bed all morning Correct Answer: C
19. A client with a history of gastroesphageal reflux disease (GERD), who smokes 2 packs of cigarettes and drinks a fifth of liquor daily, had a cholecystectomy. While completing a head to toe assessment, the nurse discovers that the client is tremulous, agitate, febrile, and disoriented. What is the likely indication of this finding?
A. Impending delirium tremens
B. Post-surgical infection
C. Reoccurring reflux
D. Nicotine withdrawal
Correct Answer: A
20. Which prescription should the nurse anticipate administering to a client who is experiencing increased intracranial pressure secondary to a head injury?
A. Acetazolamide (Diamox)
B. Mannitol (Osmitrol)
C. Sumatriptan (Imitrex)
D. Dobutamine HCI (Dobutrex)
Correct Answer: B
21. The emergency room is alerted that a child is arriving by ambulance with a history of flu-like symptoms
for the past week. The reported vital signs are temperature 101
̊ F, heart rate 168 beats/minute,
respirations 16 breaths/minute, and blood pressure 90/60.The child is lethargic with a capillary refill time of 4 seconds. When preparing for the child’s arrival, the nurse should assemble which equipment?
A. Mechanical ventilator
B. IV infusion pump
C. Cooling blanket
D. Automated defibrillator Correct Answer: B
22. A child with heart failure is receiving the diuretic furosemide (Lasix) and has a serum potassium level of
3.0 mEq/L. Which assessment is most important for the nurse to obtain?
A. Cardiac rhythm and heart rate
B. Daily intake of foods rich in potassium
C. Hourly urinary output
D. Thirst and skin turgor Correct Answer: A
23. A male client, who had a total laryngectomy two days ago, is transferred from the intensive care unit to a private room close to the nurse’s station. The nurse recognizes that the client is anxious. Which intervention should the nurse implement?
A. Encourage a family member to stay with the client at all times
B. Answer the client’s call signal in person quickly after he calls
C. Explain the emergency procedure for loss of airway to the client
D. Provide the client with a suction catheter to allow for self-suctioning Correct
Answer: B
24. When caring for a client with an acute myocardial infarction, which observation warrants immediate intervention by the nurse?
A. Systolic blood pressure of 100
B. Oral temperature of 99.4 ̊ F
C. Central venous pressure (CVP) of 4 mm Hg
D. The telemetry displays ventricular bigamy Correct Answer: D
25. A client is admitted to the emergency center with a possible head injury and spinal cord injury (SCI) after an automobile collision. What is the nurse’s priority assessment?
A. Level of consciousness
B. Mobility of extremities
C. Respiratory status
D. Cranial nerve function Correct Answer: C
26. A school-aged child with juvenile rheumatoid arthritis develops a viral infection with a low grade fever. The child is already taking aspirin for the arthritis.
What instruction should the nurse provide to this mother?
A. Discontinue the use of all medications to avoid masking the symptoms of the illness
B. Discontinue the aspirin, and use another NSAID to control the child’s fever and symptoms
C. Continue the aspirin, but add another NSAID to control the child’s fever and symptoms
D. Increase the dose of aspirin to control the child’s fever and symptoms Correct Answer: B
27. A female teacher tells the school nurse that she thinks she is pregnant, but her pregnancy test was negative the previous night. When taking the teacher’s history, the nurse finds that the only medication the teacher is currently taking is tetracycline for acne. Which instruction should the nurse provide?
A. Make an appointment with an obstetrician as soon possible
B. Increase oral fluid intake to 3 or quarts daily
C. Use first voiding of the day for accurate results of a pregnancy test
D. Stop taking the acne medication immediately Correct Answer: D
28. Three days after admission for diabetic ketoacidosis (DKA), a client’s blood glucose levels ranges from 420 to 540 mg/dl. Regular insulin is being administered using a sliding dosage scale. Which intervention is most important for the nurse to implement?
A. Confer with the healthcare provider about a continuous IV insulin infusion
B. Arrange for a nutritional consult to assist the client with diabetic food choices
C. Request the diabetic educator to evaluate the client’s knowledge of diabetes
D. Given an additional dose of regular insulin according to sliding scale prescription Correct Answer: A
29. An adult male who recently returned from a trip to China is diagnosed with severe acute respiratory syndrome (SARS). He is hospitalized and placed in a negative pressure isolation room. Which intervention is most important to include in this client’s plan of care?
A. Determine if an advanced directive is signed
B. Require use of gown, gloves, and N-95 mask
C. Limit visitors to family members only
D. Teach how to dispose of used tissues Correct Answer: B
30. When evaluating the effectiveness of medications administered to a client with Parkinson’s disease, the nurse recognizes that symptom management requires a balance among which neurotransmitters?
A. Norepinephrine and acetylcholine
B. Epinephrine and dopamine
C. Dopamine and norepinephrine
D. Acetylcholine and dopamine
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