PN HESI EXIT V1 ALL 160 QUESTIONS & ANSWERS INCLUDED - GUARANTEED PASS A+!!! ALL BRAND NEW
A school-age client with diabetes is placed on an
... [Show More] intermediate- acting insulin and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. What does the nurse tell the client the snack is intended to do?
You Selected:
⦁ Prevent late night hypoglycemia.
Correct response:
Prevent late night hypoglycemia.
Question 2
A well-known public official of a small community is admitted to the emergency department following an episode of chest pain.
Several nurses from the medical unit are aware of the admission and access the official’s electronic medical record to obtain a status update. What is the best response for the nurse manager to make to the nurses regarding this situation?
You Selected:
⦁ “Assessing the official’s medical record is a breach of confidentiality.”
Correct response:
⦁ “Assessing the official’s medical record is a breach of confidentiality.”
Question 3
A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell (WBC) count, especially the
neutrophil count, is low. What is the most important intervention the
nurse should teach the parents?
You Selected:
⦁ Protect your child from infections because his resistance to infection is decreased
Correct response:
⦁ Protect your child from infections because his resistance to infection is decreased
Question 4
The nurse is caring for a client with influenza. The most effective way to decrease the spread of microorganisms is:
You Selected:
⦁ placing the client in isolation.
Correct response:
⦁ washing the hands frequently.
Question 5
A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure?
You Selected:
⦁ in the supine, sitting, and standing positions
Correct response:
⦁ in the supine, sitting, and standing positions
Question 6
A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further?
You Selected:
⦁ cool, pale fingers
Correct response:
⦁ cool, pale fingers
Question 7
A nurse is caring for a female client before surgery. The client states that she is glad that she will not be going through menopause as a result of her surgery and is only having her uterus removed. The nurse reviews the consent form and notes that the surgery is for a total abdominal hysterectomy with a salpingo-oophorectomy. What should the nurse do in this situation?
You Selected:
⦁ Contact the surgeon to explain that the client needs further clarification regarding surgery.
Correct response:
⦁ Contact the surgeon to explain that the client needs further clarification regarding surgery.
Question 8
A young client diagnosed with schizophrenia is talking with the nurse and says, "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I would like to get out and do things again." What is the best initial response by the nurse?
You Selected:
⦁ "What activities did you enjoy in the past?"
Correct response:
⦁ "What activities did you enjoy in the past?"
Question 9
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?
You Selected:
⦁ nausea, vomiting, and anorexia
Correct response:
⦁ dyspnea, tachycardia, and pallor
Question 10
The nurse is discontinuing an intravenous catheter on a 10-year-old client with hemophilia. What would be the most important intervention for this client?
You Selected:
⦁ Apply firm pressure on the site for 5 minutes after removal.
Correct response:
⦁ Apply firm pressure on the site for 5 minutes after removal.
Question 11
When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse’s priority assessment?
You Selected:
⦁ checking the dressing, drain, and amount of drainage
Correct response:
⦁ assessing the vital signs and oxygen saturation levels
Question 12
A client with an uncomplicated term pregnancy arrives at the labor- and-delivery unit in early labor saying that she thinks her water has broken. What is the nurse’s best action?
You Selected:
⦁ Ask what time this happened and note the color, amount, and odor of the fluid.
Correct response:
⦁ Ask what time this happened and note the color, amount, and odor of the fluid.
Question 13
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes
You Selected:
⦁ ensuring the abbreviations are understandable to clients who may seek access to their health records
Correct response:
⦁ limiting abbreviations to those approved for use by the institution
Question 14
During routine prenatal screening, a nurse tells a client that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates?
You Selected:
⦁ "This screening indicates if your baby's lungs are mature."
Correct response:
⦁ "This test will screen for spina bifida, Down syndrome, or other genetic defects."
Question 15
A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection?
You Selected:
⦁ chicken and orange slices
Correct response:
⦁ chicken and orange slices
Question 16
A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse?
You Selected:
⦁ Collaborate with the interprofessional team to make a referral to social services.
Correct response:
⦁ Collaborate with the interprofessional team to make a referral to social services.
Question 17
A client is newly diagnosed with asthma. While learning to use a metered dose inhaler (MDI) for delivery of a short-term beta agonist, the client asks if a spacer is appropriate to use with this device. What is the nurse’s best response?
You Selected:
⦁ “No, a spacer is not recommended because it can increase the risk of developing oropharyngeal candidiasis.”
Correct response:
⦁ “Yes, a spacer is recommended because it increases the
amount of medication that is delivered to the lungs.”
Question 18
The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client’s pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client’s vital signs, and the client’s score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. What should the nurse do next?
You Selected:
⦁ Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed.
Correct response:
⦁ Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed.
Question 19
The nurse is making a room assignment for a client whose laboratory test result indicate pancytopenia. Which client should the nurse put into the same room with the client with pancytopenia?
You Selected:
⦁ a client with digoxin toxicity
Correct response:
⦁ a client with digoxin toxicity
Question 20
A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which of the following?
You Selected:
⦁ A referral.
Correct response:
⦁ A referral.
Question 21
A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first?
You Selected:
⦁ the client admitted after a head injury in a motor vehicle who reports nausea
Correct response:
⦁ the client admitted after a head injury in a motor vehicle who reports nausea
Question 22
The mother of an adolescent client who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which response by the nurse is appropriate?
You Selected:
⦁ “Tell me what you’ve found in your reading that’s leading
you to that conclusion.”
Correct response:
⦁ “Tell me what you’ve found in your reading that’s leading you to that conclusion.”
Question 23
A nurse prepares a client's medication by reconstituting a multi-dose vial of medication. What other nursing interventions should the nurse take? Select all that apply.
You Selected:
⦁ Label the vial with the strength of the medication.
Store the multi-dose vial in a secure place.
⦁ Initial the vial as the person reconstituting the medication.
Correct response:
⦁ Label the vial with the strength of the medication.
⦁ Store the multi-dose vial in a secure place.
⦁ Initial the vial as the person reconstituting the medication.
Question 24
Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next:
You Selected:
⦁ discuss the situation and possible courses of action with the dietitian and the client.
Correct response:
⦁ discuss the situation and possible courses of action with the dietitian and the client.
Question 25
After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the mother agrees to seek medical advice if the child experiences which symptom?
You Selected:
⦁ fussiness and reports that the cast is heavy
Correct response:
⦁ inability to extend the fingers on the right hand
Question 26
While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at the nurse's clinic. What is the
nurse's most appropriate response?
You Selected:
⦁ "I'm sorry, I can't disclose client information."
Correct response:
⦁ "I'm sorry, I can't disclose client information."
Question 27
When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication?
You Selected:
⦁ urinary retention
Correct response:
⦁ urinary retention
Question 28
Which situation demonstrates correct principles of confidentiality?
You Selected:
⦁ Two nurses alone in an elevator are discussing a client's status.
Correct response:
⦁ An emergency department nurse reports suspected child abuse.
Question 29
The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, “Why? Everything was going well. How could they do this to me?” What response by the staff nurse reflects an understanding of the client’s borderline disorder?
You Selected:
⦁ “Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety.”
Correct response:
⦁ “Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety.”
Question 30
A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is:
You Selected:
⦁ monitoring the blood glucose level closely.
Correct response:
⦁ monitoring the blood glucose level closely.
Question 31
A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse?
You Selected:
⦁ “The drainage is an indication that the sutures were not tight enough.”
Correct response:
⦁ “If a wound heals on the surface but infection remains, it will open and drain.”
Question 32
A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next?
You Selected:
⦁ Instruct the client to use a pant-blow pattern of breathing.
Correct response:
⦁ Instruct the client to use a pant-blow pattern of breathing.
Question 33
A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks
the client's history for asthma. Acetylcysteine must be used
cautiously in a client with asthma because it
You Selected:
⦁ may induce bronchospasm.
Correct response:
⦁ may induce bronchospasm.
Question 34
Bone resorption is a possible complication of Cushing’s disease. To help the client prevent this complication, what should the nurse recommend to the client?
You Selected:
⦁ Maintain a regular program of weight-bearing exercise.
Correct response:
⦁ Maintain a regular program of weight-bearing exercise.
Question 35
A client rates the pain level of a migraine an 8 on a scale of 1-10. How would the nurse administer the medication to give the client the quickest relief?
You Selected:
⦁ intravenous (IV)
Correct response:
⦁ intravenous (IV)
Question 36
A client with Parkinson’s disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is
the mostappropriate action by the nurse?
You Selected:
⦁ Assess the nausea and weakness and call physiotherapy to cancel or reschedule the appointment.
Correct response:
⦁ Assess the nausea and weakness and call physiotherapy to cancel or reschedule the appointment.
Question 37
Which intervention should the nurse include in the plan of care to ensure adequate nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals?
You Selected:
⦁ Offer the client nutritious finger foods.
Correct response:
⦁ Offer the client nutritious finger foods.
Question 38
Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur?
You Selected:
⦁ playing a card game with other clients
Correct response:
⦁ talking with the nurse
Question 39
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the
client to
You Selected:
⦁ rest in an air-conditioned room.
Correct response:
⦁ rest in an air-conditioned room.
Question 40
An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?
You Selected:
a 10-year-old with a simple fracture of the humerus who is in severe pain
Correct response:
⦁ a middle-aged man with no injuries who has rapid respirations and coughs
Question 41
A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks’ gestation tells the nurse that she takes mineral oil for occasional constipation. What should the nurse should instruct the client to do?
You Selected:
⦁ Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins.
Correct response:
⦁ Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins.
Question 42
A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy?
You Selected:
⦁ cough and shortness of breath
Correct response:
⦁ cough and shortness of breath
Question 43
A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first?
You Selected:
⦁ Notify the unit manager.
Correct response:
⦁ Discuss the breach of practice with the physician.
Question 44
The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital?
You Selected:
⦁ Decrease the client's feelings of isolation and loneliness.
Correct response:
⦁ Decrease the client's feelings of isolation and loneliness.
Question 45
A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant
to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?
You Selected:
⦁ Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.
Correct response:
Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.
Question 46
A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should
You Selected:
⦁ collect the specimen in a sterile container.
Correct response:
⦁ collect the specimen in a sterile container.
Question 47
A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse’s priorityintervention?
You Selected:
⦁ Ask for additional information from the client.
Correct response:
⦁ Ask for additional information from the client.
Question 48
The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. The nurse should intervene if the UAP:
You Selected:
⦁ ambulates the client.
Correct response:
⦁ massages the client’s legs.
Question 49
For a client with Graves' disease, which nursing intervention promotes comfort?
You Selected:
⦁ maintaining room temperature in the low-normal range
Correct response:
⦁ maintaining room temperature in the low-normal range
Question 50
A client is admitted to the hospital because of threatening, aggressive behavior toward his family. In the first group meeting after the client is admitted, another client sits near the nurse and says loudly, "I'm sitting here because I'm afraid of Ted. He's so big, and I heard him talk about hitting people." The nurse should say to the client:
You Selected:
⦁ "Everyone is here for different problems. You know you don't have to worry."
Correct response:
⦁ "It's frightening to have new people on the unit. We're here to talk about things like being afraid."
Question 51
A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution?
You Selected:
⦁ I.V. tubing with a macrodrip chamber
Correct response:
I.V. tubing with a volume-control chamber
Question 52
What is the priority nursing intervention in the postictal phase of a seizure?
You Selected:
⦁ Assess the client's breathing pattern.
Correct response:
⦁ Assess the client's breathing pattern.
Question 53
The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm?
You Selected:
⦁ Immediately evacuate the unit.
Correct response:
⦁ Close all of the doors on the unit.
Question 54
The nurse is suctioning a client’s tracheostomy. For what reason during the procedure does the nurse complete the above action?
You Selected:
⦁ to lubricate the outside of the suction catheter
Correct response:
⦁ to clear secretions from the tubing
Question 55
A primiparous client is on a regular diet 24 hours postpartum. The client’s mother asks the nurse if she can bring her daughter some “special foods from home.” The nurse responds, based on the understanding about which principle?
You Selected:
⦁ The client’s health care provider (HCP) needs to give permission for the foods.
Correct response:
⦁ The mother can bring the daughter any foods that she desires.
Question 56
A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch-up the child’s vaccinations?
You Selected:
⦁ Contact the child’s health care provider (HCP) during office
hours.
Correct response:
⦁ Review nationally published immunization guidelines.
Question 57
A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention?
You Selected:
⦁ Monitor fetal heart tones.
Correct response:
Monitor fetal heart tones.
Question 58
A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is
the priority action by the nurse?
You Selected:
⦁ Complete an adverse drug reaction (ADR) report.
Correct response:
⦁ Report the incident to risk management.
Question 59
A multipara at 16 weeks’ gestation is diagnosed as having a fetus with probable anencephaly. The client is from a conservative faith and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. What should the nurse do?
You Selected:
⦁ Explore his or her own feelings about the issues of anencephaly and organ donation.
Correct response:
⦁ Explore his or her own feelings about the issues of anencephaly and organ donation.
Question 60
A client who is to have a vaginal radium implant tells the nurse she is concerned about being radioactive. The nurse should tell the client:
You Selected:
⦁ “The radiation is necessary to treat your tumor.”
Correct response:
”The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain.”
Question 61
An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, (2.3 mmol/L) and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting
You Selected:
⦁ 18 to 20 g of a simple carbohydrate.
Correct response:
⦁ 15 g of a simple carbohydrate.
Question 62
A competent client in a long-term care facility refuses to take oral diuretic medication. The nurse informs the client that if the medication isn’t taken, restraints will be applied, and the medication will be given by injection. Which legal tort best describes this nurse’s statement?
You Selected:
⦁ negligence
Correct response:
⦁ assault
Question 63
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?
You Selected:
⦁ lung auscultation and measurement of vital capacity and tidal volume
Correct response:
⦁ lung auscultation and measurement of vital capacity and tidal volume
Question 64
Which client should the nurse assess first?
You Selected:
⦁ a client with chronic hypertension whose blood pressure today is 182/98 mm Hg
Correct response:
⦁ a client being treated for chronic stable angina who reports a
recent increase in chest pain frequency
Question 65
A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?
You Selected:
⦁ Take a sitz bath.
Correct response:
⦁ Apply an ice pack to her perineum.
Question 66
The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the
nurse best communicate with the client?
You Selected:
⦁ Have a hospital interpreter come to the assessment; defer the assessment if none is available.
Correct response:
⦁ Enlist the help of a hospital interpreter; ask the son to translate if none is readily available.
Question 67
A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond?
You Selected:
⦁ "You should ask your physician about that." [Show Less]