PN Hesi Exit Exam V3 Questions and Answers.
1) The LPN/LVN receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which
... [Show More] action should the nurse implement?
A.Hang the solution at the current rate. B.Refrigerate the solution until needed. C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy.
Correct Answer: D Return the solution to the pharmacy.
2) A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?
A.Immediately after feeding B.Just prior to tube feeding C.Continuous inflation is required D.Inflation is not required
Correct Answer: B Just prior to tube feeding
3) A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment?
A.Administer lidocaine,75 mg intravenous push. B.Perform synchronized cardioversion.
C.Defibrillate the client as soon as possible. D.Administer atropine, 0.4 mg intravenous push.
Correct Answer: B Perform synchronized cardioversion.
4) A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which
additional symptom should the nurse expect to find?
A. Pedal pulses will be weak or absent in the left foot.
B. The client will state that the left foot is usually warm.
C. Flexion and extension of the left foot will be limited. D.Capillary refill of the client's left toes will be brisk.
Correct Answer: A Pedal pulses will be weak or absent in the left foot.
5) A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client?
A.Avoid high-carbohydrate foods. B.Decrease intake of fat-soluble vitamins.
C.Decrease caloric intake.
D.Restrict salt and fluid intake.
Correct Answer: D Restrict salt and fluid intake.
6) During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first?
A. Review the client's history for diabetes mellitus.
B. Observe the extremity distal to the IV site.
C. Monitor the client's serum potassium and blood glucose levels. D.Evaluate the client's oxygen saturation and breath sounds.
Correct Answer: C Monitor the client's serum potassium and blood glucose levels.
7) A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client?
A.Determine if all employees have had the hepatitis B vaccine series. B.Explain that this type of hepatitis can be transmitted when feeding the client. C.Assure the employees that they cannot contract hepatitis B when providing direct care.
D.Tell the employees that wearing gloves and a gown are required when providing care.
Correct Answer: A Determine if all employees have had the hepatitis B vaccine series.
8) The LPN/LVN notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take?
A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks.
C.Milk the tube to remove any excessive blood clot buildup. D.Assess for kinks or dependent loops in the tubing.
Correct Answer: D Assess for kinks or dependent loops in the tubing.
9) The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding?
A.Myocardial infarction 2 months ago B.Anorexia and vomiting for the past 2 days
C.Recently diagnosed type 2 diabetes mellitus
D.Skeletal traction for a right hip fracture
Correct Answer: B Anorexia and vomiting for the past 2 days
10) The nurse is reviewing routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question?
A.Antianginal with a therapeutic effect of vasodilation B.Anticholinergic with a side effect of pupillary dilation C.Antihistamine with a side effect of sedation D.Corticosteroid with a side effect of hyperglycemia
Correct Answer:B Anticholinergic with a side effect of pupillary dilation
11) A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine (Pneumovax). Which statement given by the
nurse would offer the client accurate information about this vaccine?
A. The vaccine is given annually before the flu season to those older than 50 years.
B. The immunization is administered once to older adults or those at risk for illness.
C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection.
D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.
Correct Answer: B The immunization is administered once to older adults or those at risk for illness.
12) The nurse is assessing a male client with acute pancreatitis. Which finding requires the MOST immediate intervention by the nurse?
A. The client's amylase level is three times higher than the normal level.
B. While the nurse is taking the client's blood pressure, he has a carpal spasm.
C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7.
D. The client states that he will continue to drink alcohol after going home.
Correct Answer: B While the nurse is taking the client's blood pressure, he has a carpal spasm.
13) During assessment of a client in the intensive care unit, the nurse notes that the client's ARE CLEAR UPON AUSCULTATION, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement?
A.Prepare the client for a pericardial tap. B.Administer intravenous furosemide (Lasix). C.Assist the client to cough and breathe deeply.
D.Instruct the client to restrict the oral fluid intake. Correct Answer: A. Prepare the client for a pericardial tap.
14) After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation?
A. Switch to skim milk.
B. Switch to orange juice.
C. Add a source of protein.
D. Add herbal tea.
Correct Answer: A Switch to skim milk.
15) A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first?
A. Support the client to a sitting position.
B. Ask the client to walk slowly back to the room. C.Administer a sublingual nitroglycerin tablet.
D.Provide oxygen via nasal cannula.
Correct Answer: A. Support the client to a sitting position.
16) A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse?
A. Fever of 102° F
B. Blood pressure of 150/90 mm Hg C.Abdominal cramping
D.Dry mucous membranes
Correct Answer: A Fever of 102° F
17) A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit implement first?
A. Instruct the nursing staff to close all window blinds and curtains in clients' rooms.
B. Move clients and visitors into the hallways and close all doors to clients' rooms.
C. Visually confirm the location of the tornado by checking the windows on the unit.
D. Assist all visitors with evacuation down the stairs in a calm and orderly manner.
Correct Answer: B. Move clients and visitors into the hallways and close all doors to clients' rooms.
18) A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client?
A.Vitamin K1 (AquaMEPHYTON), 5 mg IM daily B.High-calorie, low-sodium diet
C.Fluid restriction to 1500 mL/day
D.Pentobarbital (Nembutal sodium) at bedtime for rest
Correct Answer: D. Pentobarbital (Nembutal sodium) at bedtime for rest
19) A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides?
A.Azotemia B.Oliguria C.Hyperkalemia D.Nephron obstruction
Correct Answer: D Nephron obstruction
20) Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome?
A. "Get immunization against human papillomavirus (HPV)."
B. "Change your tampon frequently."
C. "Empty your bladder after intercourse."
D. "Obtain a yearly flu vaccination."
Correct Answer: B. "Change your tampon frequently."
21) A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the
nurse?
A.Hypoactive bowel sounds with abdominal distention B.Client reports continued pain of 8 on a 10-point scale
C.Respiratory rate of 12 breaths/min, with O2 saturation of 85% D.Client reports nausea after receiving the medication
Correct Answer: C Respiratory rate of 12 breaths/min, with O2 saturation of 85%
22) A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family?
A.Follow exposure precautions. B.Encourage regular meals.
C.Collect all urine.
D.Avoid touching the client.
Correct Answer: A.Follow exposure precautions.
23) An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to implement for this client?
A. Initiate airborne infection precautions.
B. Place a surgical mask on the client.
C. Don an isolation gown and latex gloves.
D. Start protective (reverse) isolation precautions.
Correct Answer: A.Initiate airborne infection precautions.
24) Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy?
A.Hypokalemia B.Microalbuminuria C.Elevated serum lipid levels
D.Ketonuria
Correct Answer: B.Microalbuminuria
25) An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client?
A.Leukocytosis and febrile B.Polycythemia and crackles C.Pharyngitis and sputum production D.Confusion and tachycardia
Correct Answer: D Confusion and tachycardia
26) Which nursing action is necessary for the client with a flail chest?
A.Withhold prescribed analgesic medications. B.Percuss the fractured rib area with light taps. C.Avoid implementing pulmonary suctioning. D.Encourage coughing and deep breathing.
Correct Answer: D Encourage coughing and deep breathing.
27) When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN?
A.A young adult with bacterial meningitis with recent seizures B.An older adult client with pneumonia and viral meningitis
C.A female client in isolation with meningococcal meningitis
D.A male client 1 day postoperative after drainage of a brain abscess
Correct Answer: B An older adult client with pneumonia and viral meningitis
28) When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching?
A.Recommend that the client carry suction equipment at all times. B.Instruct the client to have writing materials with him at all times.
C.Tell the client to carry a medical alert card that explains his condition.
D.Caution the client not to travel outside the United States alone.
Correct Answer: C. Tell the client to carry a medical alert card that explains his condition.
29) A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication?
A. Assess for signs of jugular venous distention.
B. Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D. Flush the line with normal saline.
Correct Answer: D.Flush the line with normal saline.
30) In caring for a client with acute diverticulitis, which assessment data warrants immediate nursing intervention?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C. The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. Correct Answer: A.The client has a rigid hard abdomen and elevated WBC.
31) The nurse is giving preoperative instructions to a 14-year-old client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place?
A. "I will read all the teaching booklets you gave me before surgery."
B. "I have had surgery before, so I know what to expect afterward."
C. "All the things people have told me will help me take care of my back."
D. "Let me show you the method of turning I will use after surgery."
Correct Answer: D."Let me show you the method of turning I will use after surgery."
32) The nurse on a medical surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain?
A. If suctioning will be needed for drainage of the wound
B. If the family would prefer a private or semiprivate room
C. If the client also has a Hemovac in place
D. If the client's wound is infected
Correct Answer: D If the client's wound is infected
33) The nurse is completing an admission interview for a client with Parkinson's disease. Which question will provide additional information about manifestations that the client is likely to experience?
A. "Have you ever experienced any paralysis of your arms or legs?"
B. "Do you have frequent blackout spells?"
C. "Have you ever been frozen in one spot, unable to move?"
D. "Do you have headaches, especially ones with throbbing pain?"
Correct Answer: C. "Have you ever been frozen in one spot, unable to move?"
34) A hospitalized client is receiving nasogastric tube feedings via a small- bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take FIRST?
A.Auscultate the client's breath sounds. B.Turn off the continuous feeding pump.
C.Check placement of the nasogastric tube.
D.Measure the amount of residual feeding.
Correct Answer: B.Turn off the continuous feeding pump.
35) The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the
client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect?
A.Increased serum albumin level B.Decreased serum creatinine C.Decreased serum ammonia level D.Increased liver function test results
Correct Answer: C.Decreased serum ammonia level
36) During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take?
A. Continue with the shift report and talk to the nurse about the incident at a later time.
B. Ask the nurse to call the house supervisor to see if she must be reassigned.
C. Stop the shift report and remind the nurse that all staff are floated equally.
D. Inform the nurse that her behavior is disruptive to the rest of the staff.
Correct Answer: A.Continue with the shift report and talk to the nurse about the incident at a later time. [Show Less]