HESI RN Exit V3| Questions and Verified Answers| 100% Correct| Grade A (2024/ 2025)
QUESTION
An adult recently diagnosed with glaucoma, tells the
... [Show More] nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?
a. Wear prescription glasses. b. Eat a diet high in carotene.
c. Avoid frequent eye pressure measurements.
d. Maintain prescribed eyedrop regimen
Answer:
d. Maintain prescribed eyedrop regimen
Glaucoma is a condition characterized by increased intraocular pressure (IOP), which can lead to damage to the optic nerve and vision loss. The primary treatment for glaucoma often involves the use of prescribed eyedrops to lower intraocular pressure and prevent further damage to the optic nerve. Adherence to the prescribed eyedrop regimen is crucial for managing and slowing the progression of the disease.
QUESTION
The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? A client:
a. with pneumonia whose serum potassium level is 6.5 mg/dl. b. with atrial fibrillation, whose saline lock is infiltrated
c. who is receiving a heparin infusion and has developed hematuria.
d. with hypertension whose blood pressure is 230/118.
Answer:
b. with atrial fibrillation, whose saline lock is infiltrated
This assignment involves a client with atrial fibrillation, which is a common cardiac rhythm disorder. The issue of a saline lock infiltration is relatively routine and can be managed with appropriate nursing interventions such as restarting the saline lock and monitoring the site. It provides the new graduate nurse an opportunity to
gain experience in handling a common issue while caring for a client with a cardiac condition.
QUESTION
Penicillin G procaine 240,000 units intramuscularly is prescribed for a
4-year-old child who has a streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2 mL. How many mL should the nurse admin- ister? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
Answer:
0.4 mL
QUESTION
A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?
a. Place the client in Trendelenburg. b. Administer oxygen via face mask. c. Notify the operating room team.
d. Administer a fluid bolus of 500 mL.
Answer:
a. Place the client in Trendelenburg.
Placing the client in Trendelenburg position helps alleviate pressure on the umbilical cord by allowing the presenting part of the baby to move away from the cord. This can help maintain fetal oxygenation while further interventions are prepared and implemented.
QUESTION
A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While taking the blood pressure, the client begins
to demonstrate cloudy consciousness, stupor, and has slurred speech. The nurse obtains a blood glucose 50 mg/dL (2.77 mmol/L), heart rate of 116 beats/minute, and blood pressure of 88/50 mmHg.. Which intervention is most important for the nurse to implement?
a. Position client with head flat and feet elevated
b. Suggests obtaining a medical alert bracelet to be always worn.
c. Encourage the client to eat low-carbohydrate and high-protein meals.
d. Reinforce the need to continue the outpatient clinic therapy.
Answer:
a. Position client with head flat and feet elevated
Positioning the client with the head flat and feet elevated can help improve blood flow to the brain and prevent syncope (fainting) due to low blood pressure. This is the immediate action needed to address the client's altered level of consciousness and prevent further deterioration.
QUESTION
The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?
a. Exercise in a swimming pool.
b. Splint affected joints during activity.
c. Perform passive range of motion exercises twice daily.
d. Begin a training program lifting weights and running.
Answer:
a. Exercise in a swim- ming pool.
Swimming and water-based exercises are generally recommended for individuals with JIA because they provide a low-impact way to strengthen muscles and improve joint mobility without putting excessive stress on the joints. The buoyancy of water supports the body, reducing the risk of joint injury or exacerbation of symptoms.
QUESTION
The nurse is educating a client in end-stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the client's daily diet?
a. The intake of protein should be increased to stimulate the kidney's nephrons function.
b. The intake of protein should be increased due to its loss through the filter membrane.
c. The protein intake should be decreased to prevent nitrogenous waste buildup.
d. The intake of protein should be decreased due to the progressively failing function of the kidney.
Answer:
c. The protein intake should be decreased to prevent nitrogenous waste buildup.
In end-stage kidney failure, the kidneys are unable to efficiently filter and remove waste products from the blood, including nitrogenous waste products like urea. High
protein intake can lead to the accumulation of these waste products, increasing the risk of uremia and other complications. Therefore, reducing protein intake is often recommended to help manage the condition and decrease the workload on the kidneys.
QUESTION
A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires Immediate In- tervention by the nurse?
a. Orientation to person and place only. b. Unequal bilateral hand grip strengths
c. Pupillary changes to ipsilateral dilation.
d. Left-sided facial drooping and dysphagia.
Answer:
c. pupillary changes to ipsilateral dilation
Pupillary changes, especially unilateral dilation (on the same side as the stroke), can indicate increased intracranial pressure and herniation, which are medical emergencies requiring immediate intervention.
QUESTION
As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids based on which pathophysiological process?
a. Removing gastric secretions and to relieve abdominal distention. b. Reducing hydrochloric acid secretion.
c. Restoring and maintaining a positive fluid balance.
d. Decreasing the formation and secretion of pancreatic enzymes. [Show Less]