HESI EXIT RN V5 160 Latest Questions
1. Suicide precautions are initiated for a child admitted to the mental health unit following an intentional
... [Show More] narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement?
Remove cigarettes for the client's room
2. A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.)
A.)A client must be willing to accept palliative care, not curative care.
B.)The healthcare provider must project that the client has 6 months or less to live.
C.)The client must be diagnosed with clinical depression
D.)The client must be of sound mind
A,B
3. A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan?
Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
4. An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?
Digoxin
5. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?
Supervise a newly hired graduate nurse during an admission assessment.
6. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?
Ask the client what he is thinking about at his time.
7. After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
A.)Administer PRN nebulizer treatment.
B.)Obtain 12 lead electrocardiogram.
C.)Monitor continuous oxygen saturation.
D.) Lay the client in the prone position
A,B,C
8. The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?
Administer a prescribed analgesia for pain.
9. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?
Use sunblock or protective clothing when outdoors.
10. Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? SATA
A.) Tell the client that its a mild reaction
B.)Notify the food services department of the allergy.
C.)Enter the allergy information in the client's record.
D.)Add egg allergy to the client's allergy arm band.
B,C,D
11. The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement?
Perform bilateral chest auscultation.
12. After administering an antipyretic medication. Which intervention should the nurse implement?
Encouraging liberal fluid intake
13. A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?
Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider
14. After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first?
Determine client's pulse, blood pressure, and respirations
15. The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply)
A.)Take postoperative vital signs for a client who has an epidual following knee arthroplasty
B.)Collect a sputum specimen for a client with a fever of unknown origin
C.)Ambulate a client who had a femoral-popliteal bypass graft yesterday
A,B,C
16. A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement?
Raise the head of the bed to a Fowler's position and support his arms with a pillow
17. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next?
Administer the analgesic as requested
18. The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)
12160
19. A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?
A.)Observe aspiration site.
B.)Assess body temperature
C.)Monitor skin elasticity
D.)Measure urinary output
A
20. An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?
Reinforce the importance of annual papanicolaou (Pap) smears.
21. A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?
Establish a structured routine for the client to follow.
22. A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?
Ventricular arrhythmias.
23. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?
Instruct the mother to change the child's diaper more often.
24. A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?
Encourage the client to eat finger foods.
25. A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?
Bowel patterns
26. While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?
Contact the medical records department supervisor.
27. A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
83
28. While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first?
Submit a referral for an evaluation by a physical therapist.
29. A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement?
Submit a referral for an evaluation by a physical therapist.
30. A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?
Reposition the client with the head of the bed elevated.
31. 155. After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?
Hold oral intake until swallow evaluation is done.
32. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply)
A.)Interacts with a flat affect.
B.)Avoids eye contact.
C.)Makes dull eye contact
D.)Has a disheveled appearance.
A,B,D
33. A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement?
Transfer the client to the surgical floor.
34. In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
A.)Place personal religious artifacts on the body.
B.)Attach identifying name tags to the body.
C.)Follow cultural beliefs in preparing the body.
D.) Inform the family
A,B,C
35. An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?
Be alert for possible cross-sensitivity to cephalosporin agents.
36. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
The client's need for pain medication should be determined.
37. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.)
A.)Monitor abdominal girth.
B.)Increase oral fluid intake to 1500 ml daily.
C.)Report serum albumin and globulin levels.
D.)Provide diet low in phosphorous.
E.)Note signs of swelling and edema.
A,C,E
38. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?
Report weight gain of 2 pounds (0.9kg) in 24 hours
39. Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?
Aural migraine headaches.
40. When implementing a disaster intervention plan, which intervention should the nurse implement first?
A.)Initiate the discharge of stable clients from hospital units
B.)Identify a command center where activities are coordinated
C.)Assess community safety needs impacted by the disaster
D.)Instruct all essential off-duty personnel to report to the facility
B
41. The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis?
Fever and dysuria.
42. A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement?
Maintain both lower extremities elevated on pillows.
43. A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care?
Teach family proper range of motion exercises.
44. The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?
Postmenopausal women need an intake of at least 1,500 mg of calcium daily.
45. When evaluating a client's rectal bleeding, which findings should the nurse document?
Color characteristics of each stool.
46. The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound?
A.)High pitched or fine crackles.
B.)Rhonchi
C.)High pitched wheeze
D.)Stridor
A
47. An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?
Explain the reason for using only non-narcotics.
48. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)
Weigh the client and report any weight gain.
Report any client complaint of pain or discomfort.
Note and report the client's food and liquid intake during meals and snacks.
49. Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care?
Medicate as needed for pain and anxiety.
50. An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries?
Decrease prevalence of glaucoma in the population. [Show Less]