V3 2020 NURSING 1 2020 HESI RN EXIT v3 With Answers.
V3 2020
NURSING nursing 1 2020
HESI RN EXIT v3
1. An adult client being admitted to the
... [Show More] psychiatric unit with a diagnosis of bipolar disorder arrives in an
elated state. What is the best room assignment the nurse can make for this client?
A) a quiet room away from the nurse’s station
B) a bright-colored room located near the recreation room
C) a room that contains very little furniture
D) a room that has at least two other clients assigned to it
2. The community health nurse is planning to visit four clients with schizophrenia. Which client should
the nurse see first?
A) a mother who took her children from school because of aliens were after them
B) a young man who has a history of substance abuse and has no telephone
C) a newly diagnosed client who needs to be evaluated for medication compliance
D) a young man recently released from prison who requires an intake assessment
3. A female client, the mother of two small children, appears depressed after learning from her healthcare
provider that she has multiple sclerosis. Which nursing intervention should the nurse implement first?
A) encourage the family to be available to the client as much as possible
B) provide the client with information about the Multiple Sclerosis Society
C) sit quietly with the client and answer questions she may ask
D) leave the room so the client has privacy to grieve
4. Which statement by a client with emphysema indicates the best understanding of the purpose of
pulmonary function testing?
A) “I won’t pass the test because I smoke and have emphysema”
B) “It will measure how well my lungs are working”
C) “This test measures how much oxygen I have in my lungs”
D) “I’m afraid I’ll find out that I have lung cancer”
5. An adolescent male client is admitted to the hospital. Based on Erikson’s theory of psychosocial
development, which nursing intervention best assists this adolescent’s adjustment to his hospital stay?
A) invite him to participate in the evening group activity
B) schedule frequent private phone calls to his parents
C) provide access to a variety of video games in his room
D) encourage him to learn his way around the hospital
6. Which individual may legally sign an informed consent?
A) a 16-year-old mother for her newborn
B) the friend of an 84-year-old married client
C) a 56-year-old who questions a proposed treatment plan
D) a 42-year-old client who is sedated
7. The nurse is working on a psychiatric unit is concerned about providing ethical and legally defensible
care for clients on the unit. Which occurrence is an indication that a client’s civil rights are being violated?
A client who
A) is anorexic is not allowed to go to the bathroom after meals unless accompanied by a staff member
B) attempted suicide recently is not allowed to wear a belt or have shoelacesV3 2020
C) made threatening phone calls is allowed to make phone calls only under the supervision of a staff
member
D) refused to take an oral psychiatric medication is administered the same medication as an IM
injection
8. Which statement by the mother of a toddler girl indicates to the nurse that a scheduled vaccine should
not be administered?
A) “Her arms gets all red and hurts a lot every time she gets a vaccination”
B) “Her throat closed up so bad she couldn’t breathe the last time she got this shot”
C) “My child has been running a little fever and has a runny nose and cough”
D) “Her baby brother has a virus and has had diarrhea for three days now”
9. Thirty-six hours after delivery, the nurse assesses a client’s fundus just above the umbilicus and
displaced to the right of midline. What action should the nurse take first?
A) assess the amount of lochia
B) ask the client when her last bowel movement occurred
C) catheterize the client and record the amount
D) palpate the bladder for distention
10. A hospitalized 81-year-old female client has numerous complaints and uses her call button often to
summon staff to help her with activities that she is capable of performing for herself. Which plan might be
most beneficial in dealing with this client?
A) set up a meeting with the client, her family, and all staff members to discuss the client’s demands
B) check on the client at designated time intervals and let the client know when the nurse will
return
C) ask the nursing supervisor to move the client to another unit where the nurse-client ratio is higher
D) rotate assignment of this client among staff members so that one nurse is not overworked
11. When giving a cooling bath to reduce the fever of a 3-year-old child, which action should the nurse
include?
A) gently massage the arms and legs with rubbing alcohol
B) pour tepid water over the child’s back and chest
C) stroke the child’s abdomen with cooling lotion
D) apply an ice pack to the back of the child’s neck
12. The nurse determines that a client has a potential (high risk) problem. What is important for the
nurse to do when planning care? A) document the current manifestations of the problem
B) limit the number of interventions being planned
C) direct nursing actions toward reducing risk factors
D) Identify the problem as having a low priority
13. The nurse notes that the influenza immunization rates are much lower for certain demographic
groups than for others. Which intervention is likely to be most useful in increasing the rates of
immunization in these low immunization groups?
A) legislative proposal that mandates influenza vaccinations for all
B) designated clinics conveniently located in target neighborhoods
C) reports describe influenza rates during times of greatest prevalence
D) radio announcements about the availability of the influenza vaccineV3 2020
14. The first time a male client stands at the bedside following a total hip replacement, he reports severe
pain in his left calf. What intervention should the nurse take first?
A) remind the client of the importance of postoperative mobility
B) use a pain scale to evaluate the severity of the pain
C) return the client to bed and assess the lower extremities
D) transfer the client to a chair and elevate the lower extremities
15. A client is receiving an IV of 5% dextrose in Lactated Ringer’s solution at a rate of 100 ml/hour. The
client tells the nurse, “I don’t need to eat because I’m getting all the nutrition I need through this IV
needle.” What initial response would be best for the nurse to provide this client?
A) “It is very important to keep eating. Why don’t you want to eat?”
B) “The IV does contain nutrients, but eating is very important”
C) “This IV is called hypertonic, and is more concentrated than your blood”
D) “Only a very small amount of the calories you need are provided by your IV”
16. The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement
by the client confirms this assessment?
A) “The nurse at night is trying to poison me with pills”
B) “The voices are telling me to kill the next person I see”
C) “The fire is burning my skin away right now”
D) “The snakes on the wall are going to eat me”
17. A male client returns to the acute care unit following surgery with sequential compression devices in
place. The nurse observes that the client dorsiflexes his feet frequently. What action should the nurse
implement?
A) advise the client to avoid flexing his feet while wearing the compression devices
B) offer to massage the client’s feet and legs while assisting him with personal care
C) remove the sequential compression devices while the client exercises his feet
D) encourage the client to perform foot exercises regularly while his mobility is limited
18. Which statement by a 16-year-old male client with acute osteomyelitis in his leg indicates the best
understanding of the appropriate activity level for his disorder?
A) “During this illness, I need to keep my leg as immobile as possible”
B) “As long as I don’t re-injure my leg, I can resume my normal activities”
C) “I need to exercise my leg as much as possible to maintain muscle tone”
D) “I will not be able to participate in contact sports ever again”
19. The nurse has conducted a cancer prevention community education program. In evaluating the
participants’ understanding of the carcinogens, what statement indicates an accurate understanding?
A) environmental factors such as sunlight and chemicals can cause cancer to spread
B) substances that change a cell so that it becomes cancerous are potential sources of cancer
C) carcinogens are in the environment and cannot be avoided
D) carcinogens are substances that contain cancerous cells
20. A 25-year-old female client is diagnosed with endometriosis by her headline provider. Which nursing
diagnosis has the highest priority?
A) low self-esteem related to potential infertility
B) anxiety related to the possibility of surgical intervention
C) pain related to extrauterine tissue inflammation
D) anxiety related to the fear of infertilityV3 2020
21. The charge nurse is supervising a newly licensed practical nurse (PN) who is administering
medications. The PN notes that a client with exophthalmos is scheduled to receive artificial tear drops.
What action should the charge nurse implement?
A) instruct the PN to hold the medication until the healthcare provider is contacted
B) remind the PN to evaluate the effectiveness of the medication after administration
C) change staff assignments so an RN can administer medications to this client
D) advise the PN that the charge nurse will administer the medication to this client
22. The charge nurse is assessing the morning lab work on four clients. Which client’s laboratory findings
should prompt the charge nurse to contact the healthcare provider immediately?
A) a 35-year-old diagnosed with pneumonia having a white blood cell (WBC) of 13,000 mm3
B) a 29-year-old diagnosed with ulcerative colitis having a serum potassium level of 3.1 mEq/L
C) a 74-year-old diagnosed with COPD who has ABGs of pH 7.35, PaCO2 49, PaO2 74, HCO3 26
D) a 50-year-old diagnosed with myocardial infarction who has an elevated CPK-MB on serial cardiac
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