HESI RN Exit practice test
In-class activity
A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain in
... [Show More] the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take? A. Elevate the legs and medicate for pain. B. Apply firm pressure to the femoral artery. C. Keep the client in bed in the supine position. D. Encourage the client to exercise the leg. - ANSWER-C A male client who lives in an area endemic with Lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide? A. Cover the ticks with oil to suffocate and kill them to prevent transmission. B. Look for early signs of a lesion that increases in size with a red border, clear center. C. See a healthcare provider if nausea, vomiting, and joint pain occur after a tick bite. D. Obtain early treatment with antiviral agents to prevent cardiac manifestations. - ANSWER-B The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client? A. Suction for only 5 seconds since the client has only one lung and cannot hold his breath for very long. B. Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning. C. Have another person available to hold the client's hands to prevent inadvertent removal of the suction tube. D. Suction deeply and vigorously to ensure that all secretions are removed in order to prevent atelectasis. - ANSWER-B The nurse is preparing to administer a prescribed dose of acetylcysteine (Mucomyst) 600 mg PO. The 10 ml vial is labeled "Mucomyst 20% solution (20 grams/100 ml)." What volume of medication in milliliters should the nurse administer? (Enter numeric value only.) - ANSWER-3mL Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers? Case manager. Nurse-manager. Quality manager. Discharge manager. - ANSWER-Case manager The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function? A. Unequal pupils. B. Loss of central reflexes. C. Inability to open the eyes. D. Change in level of consciousness [Show Less]