IHP HESI RN EXIT STUDY MATERIAL 2022/ IHP HESI RN EXIT STUDY
MATERIAL:
A client with end stage liver failure is declared brain dead. The family wants to
... [Show More] discontinue
feeding and donate and viable organs. Which action should the nurse take?
CONTACT THE REGIONAL ORGAN PROCUREMENT AGENCY
The nurse is caring for a client immediately after insertion of a PICC line. Suddenly the
client becomes anxious and tachycardia, and loud churning is heard over the pericardium
upon auscultate. What action should the nurse take first?
PLACE CLIENT IN TRENDELENBURG POSITION ON LEFT SIDE
A female client was recently diagnosed with myasthenia gravis MG is receiving
pyridostigmine bromide five times daily. Before administering the evening dose , the nurse
notes that the client was stronger than she was earlier in the day. What action should the
nurse take?
ADMINISTER THE SCHEDULE DOSE OF THE MEDICATION
A client with pelvic inflammatory disease is receiving an intermittent infusion of
erythromycin lactobionate for injection, USP, 500mg every 6 hours. The pharmacy provides
a 100ml normal saline solution wiith erythromycin 5mg/ml to infuse over 2 hours. The
nurse should program the infusion pump to deliver how many ml/hr ?
5ML/ML x 100ML=500 MG (USE D/H x Q)
500mg/500mg x 100= 100ml/2 hrs =50ml/hr
A male client with altered mental status is admitted to the intensive care unit following a
motor collision. He is short of breath, lethargic and initial arterial blood gas (ABG) results
are pH7.32, PaCO2, 62 mmHg HCO, 35 mEq/L. Which assessment finding warrants
immediate intervention by the nurse?
REGULAR PERIODS OF TEN SECOND APNEA
When providing diet teaching for a client with with cholecystitis, which types of food choice
should the nurse recommend to the client?
LOW FAT
A primigravida at 31 weeks gestation is admitted with a bloody show and contractions
every 10 minutes. After administering betamethasone, which laboratory finding should the
nurse monitor?
LECITHIN-SPHINOGOMYELIN RATIO
The Unlicensed assistive personnel (UAP) is preparing to turn and position a client with
multiple myeloma. The nurse advises the UAP to use caution when positioning this client,
since the client is at high risk for
EXCESSIVE BLEEDING AND BRUISING
A male client who was hit by a car while dodging through traffic is admitted to the
emergency department with signs of increased intracranial pressure (ICP). A computerized
tomography (CT) scans reveals an intracranial bleed. After evacuation of the hematoma,
postoperative prescriptions include: intubation with controlled mechanical ventilation to
PaCO2 of 32 to 37mmHg. What is the pathophysiological basis for this ventilator setting?
HYPOCAPNEA REDUCES ICP
An older adult woman, who has a long history of alcohol abuse, is brought to the emergency
department by her husband because he believes his wife is in the final stages of alcoholism.
The client is admitted to the medical unit with a diagnosis of cirrhosis of the liver. Which
interventions should the nurse include in this clients plan of care?
MONITOR THE CLIENT OFR BLEEDING AND SIGNS OF SHOCK
MEASURE THE CLIENTS ABDOMIANL GIRTH DAILY
DETERMINE THE CLIENTS ORIENTATION TO TIME AND PLACE
Lactulose is prescribed for a client with hepatic encephalopathy. Which interventions
should the nurse implement to evaluate its effectiveness?
MONITOR THE CLIENT SERUM AMMONIA LEVELS
The client reports a significant weight gain since the initiation of corticosteroid therapy.
What additional assessment should the nurse obtain?
CHANGE IN SKIN AND FAT DISTRIBUTION
One week after being bitten by a tick, an adult male calls the clinic nurse because he has
developed a rash at the site of the tick bite. He further describes his lack of energy, a
constant dull headache, and joint pain. Which instructions should the nurse provide the
client?
MAKE AN APPOINMENT TO BE SEEN TODAY TO START ANTIBIOTIC TREATMENT
A client admitted to the telemetry unit is having chest pain after receiving 3 sublingual
nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus
bradycardia with ST elevation. In what order should the nurse implement these nursing
actions?
CALL THE RAPID RESPONSE TEAM TO ASSIST
MOVE THE CRASH CART TO THE CLIENT ROOM
NOTIFY THE CLIENTS HEALTH CARE PROVIDER
INFORM THE FAMILY OF THE CRITICAL SITUATION
A client in the CCU suffered a myocardial infarction two days ago. Current ABG: are pH 7.36,
PaCO2 80, Paco2, 48, HCO 25,. What is the correct interpretation the nurse should have
about the client’s condition based on the ABGS values?
(answer is A) [Show Less]