NURS 4470 2019 HESI EXIT V1( COMPLETE SOLUTION)
1. Which information is a priority for the RN to reinforce to an older client
after
intravenous
... [Show More] pylegraphy?
A) Eat a light diet for the rest of the day
B) Rest for the next 24 hours since the preparation and the test is tiring.
C) During waking hours drink at least 1 8-ounce glass of fluid every hour
for the next 2
days
D) Measure the urine output for the next day and immediately notify the
health care
provider if it should decrease.
The correct answer is D: Measure the urine output for the next day and
immediately
notify the health care provider if it should decrease.
2. A client has altered renal function and is being treated at home. The
nurse recognizes
that the most accurate indicator of fluid balance during the weekly visits
is
A) difference in the intake and output
B) changes in the mucous membranes
C) skin turgor
D) weekly weight
The correct answer is D: weekly weight
3. A client has been diagnosed with Zollinger-Ellison syndrome.Which
information is
most important for the nurse to reinforce with the client?
A)It is a condition in which one or more tumors called gastrinomas form in
the pancreas
or in the upper part of the small intestine (duodenum)
B)It is critical to report promptly to your health care provider any fndings
of peptic
ulcers
c)Treatment consists of medications to reduce acid and heal any peptic
ulcers and, if
possible, surgery to remove any tumors
D)With the average age at diagnosis at 50 years the peptic ulcers may
occur at unusual
areas of the stomach or intestine
The correct answer is B: It is critical to report promptly to your health care
provider any
fndings of peptic ulcers .4. A primigravida in the third trimester is hospitalized for preeclampsia.
The nurse
determines that the client’s blood pressure is increasing. Which action
should the nurse
take frst?
A) Check the protein level in urine
B) Have the client turn to the left side
C) Take the temperature
D) Monitor the urine output
The correct answer is B: Have the client turn to the left side
5. The nurse is caring for a client in atrial fbrillation. The atrial heart rate
is 250 and the
ventricular rate is controlled at 75. Which of the following fndings is
cause for the most
concern?
A) Diminished bowel sounds
B) Loss of appetite
C) A cold, pale lower leg
D) Tachypnea
The correct answer is C: A cold, pale lower leg
6. The client with infective endocarditis must be assessed frequently by
the home health
nurse. Which fnding suggests that antibiotic therapy is not effective, and
must be
reported by the nurse immediately to the healthcare provider?
A) Nausea and vomiting
B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
C) Diffuse macular rash
D) Muscle tenderness
The correct answer is B: Fever of 103 degrees F (39.5 degrees C)
7. A client who had a vasectomy is in the post recovery unit at an
outpatient clinic. Which
of these points is most important to be reinforced by the nurse?
A) Until the health care provider has determined that your ejaculate
doesn't contain
sperm, continue to use another form of contraception.
B)This procedure doesn't impede the production of male hormones or the
production of
sperm in the testicles. The sperm can no longer enter your semen and no
sperm are in
your ejaculate.
C) After your vasectomy, strenuous activity needs to be avoided for at
least 48 hours. Ifyour work doesn't involve hard physical labor, you can return to your job
as soon as you
feel up to it. The stitches
generally dissolve in seven to ten days.
D)The health care provider at this clinic recommends rest, ice, an athletic
supporter or
over-the-counter pain medication to relieve any discomfort.
The correct answer is A: Until the health care provider has determined
that your ejaculate
doesn't contain sperm, continue to use another form of contraception.
8. A client who is to have antineoplastic chemotherapy tells the nurses of
a fear of being
sick all the time and wishes to try acupuncture. Which of these beliefs
stated by the client
would be incorrect about acupuncture?
A)Some needles go as deep as 3 inches, depending on where they're
placed in the body
and what the treatment is for. The needles usually are left in for 15 to 30
minutes.
B) In traditional Chinese medicine, imbalances in the basic energetic flow
of life —
known as qi or chi — are thought to cause illness.
* C) The flow of life is believed to flow through major pathways or nerve
clusters in your
body.
D) By inserting extremely fne needles into some of the over 400
acupuncture points in
various combinations it is believed that energy flow will rebalance to allow
the body's
natural healing
mechanisms to take over.
The correct answer is C: The flow of life is believed to flow through major
pathways or
nerve clusters in your body.
9. The nurse is discussing with a group of students the disease Kawasaki.
What statement
made by a student about Kawasaki disease is incorrect?
A)It also called mucocutaneous lymph node syndrome because it affects
the mucous
membranes (inside the mouth, throat and nose), skin and lymph nodes.
B)In the second phase of the disease, fndings include peeling of the skin
on the hands
and feet with joint and abdominal painC)Kawasaki disease occurs most often in boys, children younger than age
5 and children
of Hispanic descent
D)Initially fndings are a sudden high fever, usually above 104 degrees
Fahrenheit, which
lasts 1 to2 weeks
The correct answer is C: Kawasaki disease occurs most often in boys,
children younger
than age 5 and children of Hispanic descent
10. A client has viral pneumonia affecting 2/3 of the right lung. What
would be the best
position to teach the client to lie in every other hour during frst 12 hours
after admission?
A) Side-lying on the left with the head elevated 10 degrees
B) Side-lying on the left with the head elevated 35 degrees
C) Side-lying on the right wil the head elevated 10 degrees
D) Side-lying on the right with the head elevated 35 degrees
The correct answer is A: Side-lying on the left with the head elevated 10
degrees
11. A client has an indwelling catheter with continuous bladder irrigation
after
undergoing a transurethral resection of the prostate (TURP) 12 hours ago.
Which fnding
at this time should be reported to the health care provider?
A) Light, pink urine
B) occasional suprapubic cramping
C) minimal drainage into the urinary collection bag
D) complaints of the feeling of pulling on the urinary catheter The correct
answer is C:
minimal drainage into the urinary collection bag
12. A nurse is performing CPR on an adult who went into cardiopulmonary
arrest.
Another nurse enters the room in response to the call. After checking the
client’s pulse
and respirations, what should
be the function of the second nurse?
A) Relieve the nurse performing CPR
B) Go get the code cart
C) Participate with the compressions or breathing
D) Validate the client's advanced directive
The correct answer is C: Participate with the compressions or breathing
13. The nurse assesses a 72 year-old client who was admitted for right
sided congestive
heart failure. Which of the following would the nurse anticipate fnding?A) Decreased urinary output
B) Jugular vein distention
C) Pleural effusion
D) Bibasilar crackles
The correct answer is B: Jugular vein distention
14. A client with heart failure has a prescription for digoxin. The nurse is
aware that
sufcient potassium should be included in the diet because hypokalemia
in combination
with this medication
A) Can predispose to dysrhythmias
B) May lead to oliguria
C) May cause irritability and anxiety
D) Sometimes alters consciousness
The correct answer is A: Can predispose to dysrhythmias
15. A nurse assesses a young adult in the emergency room following a
motor vehicle
accident. Which of the following neurological signs is of most concern?
A) Flaccid paralysis
B) Pupils fxed and dilated
C) Diminished spinal reflexes
D) Reduced sensory responses
The correct answer is B: Pupils fxed and dilated
16. A 14 year-old with a history of sickle cell disease is admitted to the
hospital with a
diagnosis of vaso-occlusive crisis. Which statements by the client would
be most
indicative of the etiology of this crisis?
A)”I knew this would happen. I've been eating too much red meat lately."
B)”I really enjoyed my fshing trip yesterday. I caught 2 fsh."
C)”I have really been working hard practicing with the debate team at
school."
D)”I went to the health care provider last week for a cold and I have
gotten worse."
The correct answer is D: "I went to the doctor last week for a cold and I
have gotten
worse."
17. Which these fndings would the nurse more closely associate with
anemia in a 10
month-old infant?
A) Hemoglobin level of 12 g/dI
B) Pale mucosa of the eyelids and lips
C) Hypoactivity
D) A heart rate between 140 to 160The correct answer is B: Pale mucosa of the eyelids and lips
18. The nurse is caring for a client in hypertensive crisis in an intensive
care unit. The
priority assessment in the frst hour of care is
A) Heart rate
B) Pedal pulses
C) Lung sounds
D) Pupil responses
The correct answer is D: Pupil responses
19. Which of these clients who are all in the terminal stage of cancer is
least appropriate
to suggest the use of patient controlled analgesia (PCA) with a pump?
A) A young adult with a history of Down's syndrome
B) A teenager who reads at a 4th grade level
C) An elderly client with numerous arthritic nodules on the hands
D) A preschooler with intermittent episodes of alertness
The correct answer is D: A preschooler with intermittent episodes of
alertness
20. The nurse is about to assess a 6 month-old child with nonorganic
failure-to thrive
(NOFTT). Upon entering the room, the nurse would expect the baby to be
A) Irritable and "colicky" with no attempts to pull to standing
B) Alert, laughing and playing with a rattle, sitting with support
C)Skin color dusky with poor skin turgor over abdomen
D) Pale, thin arms and legs, uninterested in surroundings
The correct answer is D: Pale, thin arms and legs, uninterested in
surroundings
21. As the nurse is speaking with a group of teens which of these side
effects of
chemotherapy for cancer would the nurse expect this group to be more
interested in
during the discussion?
A) Mouth sores
B) Fatigue
C) Diarrhea
D) Hair loss
The correct answer is D: Hair loss
22. While caring for a client who was admitted with myocardial infarction
(MI) 2 days
ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit
(38.5 degrees
Celsius). The appropriate
nursing intervention is to
A) Call the health care provider immediatelyB) Administer acetaminophen as ordered as this is normal at this time
C) Send blood, urine and sputum for culture
D) Increase the client's fluid intake
The correct answer is B: Administer acetaminophen as ordered as this is
normal at this
time
23. A client is admitted for frst and second degree burns on the face,
neck, anterior chest
and hands. The nurse's priority should be
A) Cover the areas with dry sterile dressings
B) Assess for dyspnea or stridor
C) Initiate intravenous therapy
D) Administer pain medication
The correct answer is B: Assess for dyspnea or stridor
24. Which of these clients who call the community health clinic would the
nurse ask to
come in that day to be seen by the health care provider?
A) I started my period and now my urine has turned bright red.
B) I am an diabetic and today I have been going to the bathroom every
hour.
C) I was started on medicine yesterday for a urine infection. Now my
lower belly hurts
when I go to the bathroom.
D) I went to the bathroom and my urine looked very red and it didn’t hurt
when I went.
The correct answer is D: I went to the bathroom and my urine looked very
red and it
didn’t hurt when I
went.
25. A middle aged woman talks to the nurse in the health care provider’s
ofce about
uterine fbroids also called leiomyomas or myomas. What statement by
the woman
indicates more education is needed?
A) I am one out of every 4 women that get fbroids, and of women my age
– between the
30s or 40s, fbroids occurs more frequently.
B) My fbroids are noncancerous tumors that grow slowly.
C) My associated problems I have had are pelvic pressure and pain,
urinary incontinence,
frequent urination or urine retention and constipation.
D) Fibroids that cause no problems still need to be taken out.
The correct answer is D: Fibroids that cause no problems still need to be
taken out.26. An elderly client admitted after a fall begins to seize and loses
consciousness. What
action by the nurse is appropriate to do next?
A) Stay with client and observe for airway obstruction
B) Collect pillows and pad the side rails of the bed
C) Place an oral airway in the mouth and suction
D) Announce a cardiac arrest, and assist with intubation
The correct answer is A: Stay with client and observe for airway
obstruction
27. A nurse is providing care to a primigravida whose membranes
spontaneously ruptured
(ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the
vital signs were
T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148
beats/min.
Which assessment fndings taken now may be an early indication that the
client is
developing a complication of labor?
A) FHT 168 beats/min
B) Temperature 100 degrees Fahrenheit.
C) Cervical dilation of 4
D) BP 138/88
The correct answer is A: FHT 168 beats/min
28. A client with pneumococcal pneumonia had been started on
antibiotics 16 hours ago.
During the nurse’s initial evening rounds the nurse notices a foul smell in
the room. The
client makes all of these statements during their conversation. Which
statement would
alert the nurse to a complication?
A) "I have a sharp pain in my chest when I take a breath."
B) "I have been coughing up foul-tasting, brown, thick sputum."
C) "I have been sweating all day."
D) "I feel hot off and on."
The correct answer is B: "I have been coughing up foul tasting, brown,
thick sputum."
29. The nurse is performing an assessment on a client in congestive heart
failure.
Auscultation of the heart is most likely to reveal
A) S3 ventricular gallop
B) Apical click
C) Systolic murmur
D) Split S2
The correct answer is A: S3 ventricular gallop30. Which of these observations made by the nurse during an excretory
urogram indicate
a complicaton?
A) The client complains of a salty taste in the mouth when the dye is
injected
B) The client’s entire body turns a bright red color
C) The client states “I have a feeling of getting warm.”
D) The client gags and complains “ I am getting sick.”
The correct answer is B: The client’s entire body turns a bright red color
31. A client is diagnosed with a spontaneous pneumothorax necessitating
the insertion of
a chest tube. What is the best explanation for the nurse to provide this
client?
A) "The tube will drain fluid from your chest."
B) "The tube will remove excess air from your chest."
C) "The tube controls the amount of air that enters your chest."
D) "The tube will seal the hole in your lung."
The correct answer is B: "The tube will remove excess air from your
chest."
32. The nurse is reviewing laboratory results on a client with acute renal
failure. Which
one of the following should be reported immediately?
A) Blood urea nitrogen 50 mg/dl
B) Hemoglobin of 10.3 mg/dl
C) Venous blood pH 7.30
D) Serum potassium 6 mEq/L
The correct answer is D: Serum potassium 6 mEq/L
33. The nurse is caring for a client undergoing the placement of a central
venous catheter
line. Which of the following would require the nurse’s immediate
attention?
A) Pallor
B) Increased temperature
C) Dyspnea
D) Involuntary muscle spasms
The correct answer is C: Dyspnea
34. The nurse is performing a physical assessment on a client who just
had an
endotracheal tube inserted. Which fnding would call for immediate action
by the nurse?
A) Breath sounds can be heard bilaterally
B) Mist is visible in the T-Piece
C) Pulse oximetry of 88
D) Client is unable to speakThe correct answer is C: Pulse oximetry of 88
35. A nurse checks a client who is on a volume-cycled ventilator. Which
fnding indicates
that the client may need suctioning?
A) drowsiness
B) complaint of nausea
C) pulse rate of 92
D) restlessness
The correct answer is D: restlessness
36. The most effective nursing intervention to prevent atelectasis from
developing in a
post operative client is to
A) Maintain adequate hydration
B) Assist client to turn, deep breathe, and cough
C) Ambulate client within 12 hours
D) Splint incision
The correct answer is B: Assist client to turn, deep breathe, and cough
37. When caring for a client with a post right thoracotomy who has
undergone an upper
lobectomy, the nurse focuses on pain management to promote
A) Relaxation and sleep
B) Deep breathing and coughing
C) Incisional healing
D) Range of motion exercises
The correct answer is B: Deep breathing and coughing
38. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB)
from a client.
Which action should the nurse take frst?
A) Ask client to cough sputum into container
B) Have the client take several deep breaths
C) Provide a appropriate specimen container
D) Assist with oral hygiene
The correct answer is D: Assist with oral hygiene
39. The nurse is caring for a child immediately after surgical correction of
a ventricular
septal defect. Which of the following nursing assessments should be a
priority?
A) Blanch nail beds for color and refll
B) Assess for post operative arrhythmias
C) Auscultate for pulmonary congestion
D) Monitor equality of peripheral pulses
The correct answer is B: Assess for post operative arrhythmias
40. A client has a history of chronic obstructive pulmonary disease
(COPD). As the nurseenters the client's room, his oxygen is running at 6 liters per minute, his
color is flushed
and his respirations are 8 per minute. What should the nurse do frst?
A) Obtain a 12-lead EKG
B) Place client in high Fowler's position
C) Lower the oxygen rate
D) Take baseline vital signs
The correct answer is C: Lower the oxygen rate
41. A 4 year-old has been hospitalized for 24 hours with skeletal traction
for treatment of
a fracture of the right femur. The nurse fnds that the child is now crying
and the right
foot is pale with the absence of a pulse. What should the nurse do frst?
* A) Notify the health care provider
B) Readjust the traction
C) Administer the ordered prn medication
D) Reassess the foot in ffteen minutes
The correct answer is A: Notify the health care provider
42. The nurse is assessing a client 2 hours postoperatively after a femoral
popliteal
bypass. The upper leg dressing becomes saturated with blood. The
nurse's frst action
should be to
A) Wrap the leg with elastic bandages
B) Apply pressure at the bleeding site
C) Reinforce the dressing and elevate the leg
D) Remove the dressings and re-dress the incision
The correct answer is C: Reinforce the dressing and elevate the leg
43. A client is receiving external beam radiation to the mediastinum for
treatment of
bronchial cancer. Which of the following should take priority in planning
care?
A) Esophagitis
B) Leukopenia
C) Fatigue
D) Skin irritation
Review Information: The correct answer is B: Leukopenia
44. A client has a chest tube in place following a left lower lobectomy
inserted after a stab
wound to the chest. When repositioning the client, the nurse notices 200
cc of dark, red
fluid flows into the collection chamber of the chest drain. What is the
most appropriate
nursing action?A) Clamp the chest tube
B) Call the surgeon immediately
C) Prepare for blood transfusion
D) Continue to monitor the rate of drainage
The correct answer is D: Continue to monitor the rate of drainage
45. A client has returned from a cardiac catheterization. Which one of the
following
assessments would indicate the client is experiencing a complication from
the procedure?
A) Increased blood pressure
B) Increased heart rate
C) Loss of pulse in the extremity
D) Decreased urine output
The correct answer is C: Loss of pulse in the extremity
46. A 60 year-old male client had a hernia repair in an outpatient surgery
clinic. He is
awake and alert, but has not been able to void since he returned from
surgery 6 hours ago.
He received 1000 mL of IV fluid. Which action would be most likely to help
him void?
A) Have him drink several glasses of water
B) Crede’ the bladder from the bottom to the top
C) Assist him to stand by the side of the bed to void
D) Wait 2 hours and have him try to void again
The correct answer is C: Assist him to stand by the side of the bed to void
47. The nurse is caring for a client who requires a mechanical ventilator
for breathing.
The high pressure alarm goes off on the ventilator. What is the frst action
the nurse
should perform?
A) Disconnect the client from the ventilator and use a manual
resuscitation bag
B) Perform a quick assessment of the client's condition
C) Call the respiratory therapist for help
D) Press the alarm re-set button on the ventilator
The correct answer is B: Perform a quick assessment of the client''s
condition
48. The nurse is preparing a client who will undergo a myelogram. Which
of the
following statements by the client indicates a contraindication for this
test?
A) "I can't lie in 1 position for more than thirty minutes."
B) "I am allergic to shrimp."
C) "I suffer from claustrophobia."D) "I developed a severe headache after a spinal tap."
The correct answer is B: "I am allergic to shrimp."
49. The health care provider order reads "aspirate nasogastric feeding
(NG) tuber every 4
hours and check pH of aspirate." The pH of the aspirate is 10. Which
action should the
nurse take?
A) Hold the tube feeding and notify the provider
B) Administer the tube feeding as scheduled
C) Irrigate the tube with diet cola soda
D) Apply intermittent suction to the feeding tube
The correct answer is A: Hold the tube feeding and notify the provider
50. To prevent unnecessary hypoxia during suctioning of a tracheostomy,
the nurse must
A) Apply suction for no more than 10 seconds
B) Maintain sterile technique
C) Lubricate 3 to 4 inches of the catheter tip
D) Withdraw catheter in a circular motion
Applying suction for more than 10 seconds
51. An antibiotic IM injection for a 2 year-old child is ordered. The total
volume of the
injection equals 2.0 ml The correct action is to
A) administer the medication in 2 separate injections
B) give the medication in the dorsal gluteal site
C) call to get a smaller volume ordered
D) check with pharmacy for a liquid form of the medication skip
The correct answer is A: administer the medication in 2 separate
injections
52. The nurse receives an order to give a client iron by deep injection. The
nurse know
that the reason for this route is to
A) enhance absorption of the medication
B) ensure that the entire dose of medication is given
C) provide more even distribution of the drug
D) prevent the drug from tissue irritation Skip
The correct answer is D: prevent the drug from tissue irritation
53. A client with heart failure has Lanoxin (digoxin) ordered. What would
the nurse
expect to fnd when evaluating for the therapeutic effectiveness of this
drug?
A) diaphoresis with decreased urinary output
B) increased heart rate with increase respirations
C) improved respiratory status and increased urinary output
D) decreased chest pain and decreased blood pressureThe correct answer is C: improved respiratory status and increased
urinary output
54. While providing home care to a client with congestive heart failure,
the nurse is asked
how long diuretics must be taken. What is the nurse’s best response?
A) ”As you urinate more, you will need less medication to control fluid."
B) ”You will have to take this medication for about a year."
C) ”The medication must be continued so the fluid problem is controlled."
D) ”Please talk to your health care provider about medications and
treatments."
The correct answer is C: "The medication must be continued so the fluid
problem is
controlled."
55. A client is being discharged with a prescription for chlorpromazine
(Thorazine).
Before leaving for home, which of these fndings should the nurse teach
the client to
report?
A) Change in libido, breast enlargement
B) Sore throat, fever
C) Abdominal pain, nausea, diarrhea
D) Dsypnea, nasal congestion
The correct answer is B: Sore throat, fever
56. A client is recovering from a hip replacement and is taking Tylenol #3
every 3 hours
for pain. In checking the client, which fnding suggests a side effect of the
analgesic?
A) Bruising at the operative site
B) Elevated heart rate
C) Decreased platelet count
D) No bowel movement for 3 days Skip
The correct answer is D: No bowel movement for 3 days
57. A client is being maintained on heparin therapy for deep vein
thrombosis. The nurse
must closely monitor which of the following laboratory values?
A) Bleeding time
B) Platelet count
C) Activated PTT
D) Clotting time
The correct answer is C: Activated PTT
58. A client with amyotrophic lateral sclerosis has a percutaneous
endoscopic
gastrostomy (PEG) tube for the administration of feedings and
medications. Which [Show Less]