2023-2024 HESI RN Healthcare Exit Exam V1-V7 With Answers (893 Solved Questions)

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HESI RN EXIT EXAM V1-V7 (LATEST 2023-2024) / RN EXIT HESIEXAM V1,V2,V3,V4,V5,V6,V71.Following discharge teaching, a male client with duodenal ulcer tells the nurse the he willdrink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is thebest follow-up action by the nurse?•Review with the client the need to avoid foods that are rich in milk and cream2.A male client with hypertension, who received new antihypertensive prescriptions at hislast visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BPis 158/106 and he admits that he has not been taking the prescribed medication becausethe drugs make him “feel bad”. In explaining the need for hypertension control, the nurseshould stress that an elevated BP places the client at risk for which pathophysiologicalcondition?•Stroke secondary to hemorrhage3.The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admittedclient who has a seizure disorder. The client is supine and the UAP is placing soft pillowsalong the side rails. What action should the nurse implement?•Instruct the UAP to obtain soft blankets to secure to the side rails instead ofpillows.4.An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) forthe past 12 days. Which assessment finding requires immediate follow-up?•Describes life without purpose5.A 60-year-old female client with a positive family history of ovarian cancer has developedan abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau(Pap) smear results are negative. What information should the nurse include in the client’steaching plan?•Further evaluation involving surgery may be needed6.A client who recently underwear a tracheostomy is being prepared for discharge to home.Which instructions is most important for thenurse to include in the discharge plan?•Teach tracheal suctioning techniques7.In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygenreservoir bag does not deflate completely during inspiration and the client’s respiratoryrate is 14 breaths / minute. What action should the nurse implement?•Document the assessment data•Rational: reservoir bag should not deflate completely during inspiration and the client’srespiratory rate is within normal limits.8.During shift report, the central electrocardiogram (EKG) monitoring system alarms.Which client alarm should the nurseinvestigate firs?

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•Respiratory apnea of 30 seconds9.During a home visit, the nurse observed an elderly client with diabetes slip and fall. Whataction should the nurse take first?•Check the client for lacerations or fractures10.At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), theclient tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoidgetting a headache. Which action should the nurse take first?•Inform the anesthesia care provider11.After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heartsounds. To determine if an S3 heart sound is present, what action should the nurse takefirst?•Listen with the bell at the same location12.A 66-year-old woman is retiring and will no longer have a health insurance through herplace of employment. Which agency should the client be referred to by the employeehealth nurse for health insurance needs?•Medicare13.A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset.What snack should the nurse instruct the client to take with the tetracycline?•Toasted wheat bread and jelly14.Following a lumbar puncture, a client voices several complaints. What complaintindicated to the nurse that the client is experiencing a complication?•“I have a headache that gets worse when I sit up”•“I am having pain in my lower back when I move my legs”•“My throat hurts when I swallow”•“I feel sick to my stomach and am going to throw up”15.An elderly client seems confused and reports the onset of nausea, dysuria, and urgencywith incontinence. Which action should the nurse implement?•Obtain a clean catchmid-stream specimen16.The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foodsthat are in keeping with the child’s dietary restrictions. Which foods arecontraindicated for this child?•Foods sweetened with aspartame17.Before preparing a client for the first surgical case of the day, a part-time scrub nurseasks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation forthis client. Which response should the circulating nurse provide?•Direct the nurse to continuethe surgical hand scrub for a 5 minute duration18.Which breakfast selection indicates that the client understands the nurse’s instructionsabout the dietary management of osteoporosis?

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•Bagel with jelly and skim milk19.The charge nurse of a criticalcare unit is informed at the beginning of the shift that less than theoptimal number of registered nurses will be working that shift. In planning assignments, which clientshould receive the most care hours by a registered nurse (RN)?•An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foleycatheter and soft wrist restrains applied

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20.A mother brings her 6-year-old child, who has just stepped on a rusty nail, to thepediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoeand pierced the bottom of thechild’s foot. Which action should the nurse implementfirst?•Cleanse the foot with soap and water and apply an antibiotic ointment•Provide teaching about the need for a tetanus booster within the next 72 hours.•have the mother check the child's temperature q4h for the next 24 hours•transfer the child to the emergency department to receive a gamma globulininjection21.The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have beenapplying triple antibiotic ointment for two days, but there has been no improvement.”What instruction should the nurse provide?•Stop using the ointment and encourage complete drying of the feet and wearingclean socks.22.A 26-year-old female client is admitted to the hospital for treatment of a simple goiter,and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to thenurse that the prescribed dosage is too high for this client? The client experiences•Bradycardia and constipation•Lethargy and lack of appetite•Muscle cramping and dry, flushed skin•Palpitations and shortness of breath23.A client with a history of heart failure presents to the clinic with a nausea, vomiting,yellow vision and palpitations. Which finding is most important for the nurse to assess tothe client?•Obtain a list of medications taken for cardiac history24.The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver howmany ml/hour? (Enter numeric value only.)•75•Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour /1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour25.The pathophysiological mechanism are responsible for ascites related to liver failure?(Select all that apply)•Fluid shifts from intravascular to interstitial area due to decreased serum protein•Increased hydrostatic pressure in portal circulation increases fluid shifts intoabdomen•Increased circulating aldosterone levels that increase sodium and water retention26.The nurse is auscultating a client’s heart sounds. Which description should the nurse useto document this sound? (Please listen to the audio first to select the option that applies)

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•Murmur•Rationale: A murmur is auscultated as a swishing sound that is associated with theblood turbulence created by the heart or valvular defect.27.The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for aninfant. The 500mg vial is labeled with the instruction to add 5.3 ml diluent to provide aconcentration of 100 mg/ml. How many ml should the nurse administered for each dose?(Enter numeric value only. If rounding is required, round to the nearest tenth)•0.4•rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml28.The nurse notes that a client has been receiving hydromorphone (Dilaudid) every sixhours for four days. What assessment is most important for the nurse to complete?•Auscultate the client's bowel sounds•Observe for edema around the ankles•Measure the client’s capillary glucose level•Count the apical and radial pulses simultaneously•Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis andfrequently causes constipation, so it is most important to Auscultate the client'sbowel sounds29.A female client is admitted with end stage pulmonary disease is alert, oriented, andcomplaining of shortness of breath. The client tells the nurse that she wants “no heroicmeasures” taken if she stops breathing, and she asks the nurse to document this in hermedical record. What action should the nurse implement?•Ask the clientto discuss “do not resuscitate” with her healthcare provider30.A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and hasdeveloped diarrhea. The client has a new prescription to change the feeding to halfstrength. What intervention should the nurse implement?•Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour31.A female client reports that her hair is becoming coarse and breaking off, that the outerpart of her eyebrows have disappeared,and that her eyes are all puffy. Which follow-upquestion is best for the nurse to ask?•Have you noticed any changes in your fingernails?•Rationale: The pattern of reported manifestations is suggestive of hypothyroidism32.After a third hospitalization 6 months ago, a client is admitted to the hospital withascites and malnutrition. The client is drowsy but responding to verbal stimuli andreports recently spitting up blood. What assessment finding warrants immediateintervention by the nurse?•Capillaryrefill of 8 seconds•bruises on arms and legs

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•round and tight abdomen•pitting edema in lower legs33.After the nurse witnesses a preoperative client sign the surgical consent form, the nursesigns the form as a witness. What are the legal implications of the nurse’s signature onthe client’s surgical consent form? (Select all that apply)•The client voluntarily grants permission for the procedure to be done•The client is competent to sign the consent without impairment of judgment•The client understands the risks and benefits associated with the procedure34.Following surgery, a male client with antisocial personality disorder frequently requeststhat a specific nurse be assigned to his care and is belligerent when another nurse isassigned. What action should the charge nurse implement?•Advise the client that assignments are not based on clients requests35.A client with cervical cancer is hospitalized for insertion of a sealed internal cervicalradiation implant. While providing care, the nurse finds the radiation implant in the bed.What action should the nurse take?•Place the implant in a leadcontainer using long-handled forceps36.The client with which type of wound is most likely to need immediate intervention by thenurse?•Laceration•Abrasion•Contusion•Ulceration•Rationale: A laceration is a wound that is produced by the tearing of soft bodytissue. This type of wound is often irregular and jagged. A laceration wound isoften contaminated with bacteria and debris from whatever object caused the cut.37.The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma.Which intervention has the highest priority for inclusion in this client’s plan of care?•Monitor blood pressure frequently•Rationale:A pheochromocytoma is a rare,catecholamine-secreting tumor that mayprecipitate life-threatening hypertension. The tumor is malignant in 10% of casesbut may be cured completely by surgical removal. Although pheochromocytomahas classically been associated with 3 syndromes—von Hippel-Lindau (VHL)syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosistype 1 (NF1)—there are now 10 genes that have been identified as sites ofmutations leading to pheochromocytoma.38.When caring for a client who has acute respiratorydistress syndrome (ARDS), the nurseelevates the head of the bed 30 degrees. What is the reason for this intervention?•To reduce abdominal pressure on the diaphragm•to promote retraction of the intercostal accessory muscle of respiration•to promote bronchodilation and effective airway clearance•to decrease pressure on the medullary center which stimulates breathing

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•Rationale: a semi-sitting position is the best position for matching ventilation andperfusion and for decreasing abdominalpressure on the diaphragm, so that theclient can maximize breathing.39.When assessing a mildly obese 35-year-old female client, the nurse is unable to locate thegallbladder when palpating below the liver margin at the lateral border of the rectusabdominal muscle. What is the most likely explanation for failure to locate thegallbladder by palpation?•The client is too obese•Palpating in the wrong abdominal quadrant•Deeper palpation technique is needed•The gallbladder is normal•Rationale: a normalhealthy gallbladder is not palpable40.A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse ofincreased anxiety since the normal vaginal delivery of her son three weeks ago. Since sheis breastfeeding, she stopped taking her antianxiety medications, but thinks she may needto start taking them again because of her increased anxiety. What response is best for thenurse to provide this woman?•describe the transmission of drugs to the infant through breast milk•encourage her to use stress relieving alternatives, such as deep breathing exercises••Explain that anxiety is a normal response for the mother of a 3-week-old.•Rationale: there are several antianxiety medications that are not contraindicatedfor breastfeeding mothers.41.An older male client with a history of type 1 diabetes has not felt well the past few daysand arrives at the clinic with abdominal cramping and vomiting. He is lethargic,moderately, confused, and cannot remember when he took his last dose of insulin or atelast. What action should the nurse implement first?•Start an intravenous (IV) infusion of normal saline•obtain a serum potassium level•administer the client's usual dose of insulin•assess pupillary response to light•Rationale: the nurse should first start an intravenous infusion of normal saline toreplace the fluids and electrolytes because the client has been vomiting, and it isunclear when he last ate or took insulin. The symptoms of confusion, lethargy,vomiting, and abdominal cramping are all suggestive of hyperglycemia, whichalso contributes to diuresis and fluid electrolyte imbalance.42.A client who received multiple antihypertensivemedications experiences syncope due toa drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to holdthe client’s scheduled antihypertensive medication?•increased urinary clearance of the multiple medications has produced diuresis andlowered the blood pressureInform her that some antianxiety medications are safe to take whilebreastfeeding

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•the antagonistic interaction among the various blood pressure medications hasreduced their effectiveness•The additive effect of multiple medications has caused the blood pressure todrop too low•the synergistic effect of the multiple medications has resulted in drug toxicity andresulting hypotension43.Which client is at the greatest risk for developing delirium?•An adult client who cannot sleep due to constant pain.•an older client who attempted 1 month ago•a young adult who takes antipsychotic medications twice a day•a middle-aged woman who uses a tank for supplemental oxygen44.Which intervention should the nurse include in a long-term plan of care for a client withChronic Obstructive Pulmonary Disease (COPD)?•Reduce risks factors for infection•Administer high flow oxygen during sleep•Limit fluid intake to reduce secretions•Use diaphragmatic breathing to achieve better exhalation45.Which location should the nurse choose as the best for beginning a screening program forhypothyroidism?•A business and professional women's group.•An African-American senior citizens center•A daycare center in a Hispanic neighborhood•An after-school center for Native-American teens46.A female client has been taking a high dose of prednisone, a corticosteroid, for severalmonths. After stopping the medication abruptly, the client reports feeling “very tired”.Which nursing intervention is mostimportant for the nurse to implement?•Measure vital signs•Auscultate breath sounds•Palpate the abdomen•Observe the skin for bruising47.A male client reports the onset of numbness and tingling in his fingers and around hismouth. Which lab is importantfor the nurse to review before contacting the health careprovider?•capillary glucose•urine specific gravity•Serum calcium•white blood cell count48.What explanation is best for the nurse to provide a client who asks the purpose of usingthe log-rolling technique for turning?•working together can decrease the risk for back injury•The technique is intended to maintain straight spinal alignment.•Using two or three people increases client safety.•turning instead of pulling reduces the likelihoodof skin damage

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49.A client receiving chemotherapy has severe neutropenia. Which snack is best for thenurse to recommend to the client?•Baked apples topped with dried raisins50.Which action should the school nurse take first when conducting a screening forscoliosis?•Inspect for symmetrical shoulder height.51.An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports tothe charge nurse that a clienthas a weak pulse with a rate of 44 beat/ minutes. Whataction should the charge nurse implement?•Assign a practical nurse (LPN) to determine if an apical radial deficit is present52.After a sudden loss of consciousness, a female client is taken to the ED and initialassessment indicate that her blood glucose level is critically low. Once her glucose levelis stabilized, the client reports that was recently diagnosed with anorexia nervosa and isbeing treated at an outpatient clinic. Which intervention is more important to include inthis client’s discharge plan?•Encourage a low-carbohydrate and high-protein diet53.A client with a peripherally inserted central catheter (PICC) line has a fever. What clientassessment is most important for the nurse to perform?•Observe the antecubital fossa for inflammation.54.The nurse administers an antibiotic to a client with respiratory tract infection. To evaluatethe medication’s effectiveness, which laboratory values should the nurse monitor? Selectall that apply•White blood cell (WBC) count•Sputum culture and sensitivity55.A client is admitted to isolation with the diagnosis of active tuberculosis. Which infectioncontrol measures should the nurse implement?•Negative pressure environment•contact precautions•droplet precautions•protective environment56.A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). Inwhat position should the nurse place the child?•Sitting up and leaning forward57.A young adult who is hit with a baseball bat on the temporal area of the left skull isconscious when admitted to the ED and is transferred to the Neurological Unit to bemonitored for signs of closed head injury. Which assessment finding is indicative ofadeveloping epidural hematoma?•Altered consciousness within the first 24 hours after injury.58.A female client with breast cancer who completed her first chemotherapy treatmenttoday at an out-patient center is preparing for discharge. Which behavior indicates thatthe client understands her care needs

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•Rented movies and borrowed books to use while passing time at home59.Which instruction should the nurse provide a pregnant client who is complaining ofheartburn?•Eat small meal throughout the day to avoid a full stomach.60.A client is admitted to the intensive care unit with diabetes insipidus due to a pituitarygland tumor. Which potential complication should the nurse monitor closely?•Hypokalemia•Ketonuria.•Peripheral edema•Elevated blood pressure•Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result indiabetes insipidus, which causes massive polyuria and serum electrolyteimbalances, including hypokalemia, which can lead to lethal arrhythmias.61.A female client reports she has not had a bowel movement for 3 days, but now isdefecating frequent small amount of liquid stool. Which action should the nurseimplement?•Digitally check the client for a fecal impaction62.After changing to a new brand of laundry detergent, an adult male reports that he has afine itchy rash. Which assessment finding warrants immediate intervention by the nurse?•Bilateral Wheezing.63.The nurse should teach the parents of a 6 year-old recently diagnosed with asthma thatthe symptom of acute episode of asthma are due to which physiological response?•Inflammation of the mucous membrane & bronchospasm64.A 10 year old who has terminal brain cancer asks the nurse, "What will happen tomybody when I die?" How should the nurse respond?•"The heart will stop beating & you will stop breathing."65.The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This childshould be medicated for pain based on which findings? Select all that apply:•Restlessness•Clenched Fist•Increased pulse rate•Increased respiratory rate.•Increased temperature•Peripheral pallor of the skin66.Thenurse is preparing to administer an oral antibiotic to a client with unilateralweakness, ptosis, mouth drooping and, aspiration pneumonia. What is the prioritynursing assessment that should be done before administering this medication?67.nurse who is working on asurgical unit receives change of shiftreport on a group of clients for the upcoming shift. A client with which conditionrequires the most immediate attention by the nurse?•Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing.•Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-prattdrain.•Determine which side of the body is weak.The

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•Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collectioncontainer•Abdominal-perineal resection 2 days ago with no drainage on dressing whohas fever and chills.•Rationale: the client with an abdominal-perineal resection is at risk for peritonitisand needs to be immediately assessed for other signs and symptoms for sepsis.68.The nurse is caring for a client who had gastric bypass surgery yesterday. Whichintervention is most important for the nurse to implement during the first 24postoperative hours?•Measure hourly urinary output.•Rationale: a serious early complications of gastric bypass surgery is ananastomoses leak, often resulting in death.69.When preparing to discharge a male client who has beenhospitalized for an adrenalcrisis, the client expresses concern about having another crisis. He tells the nurse that hewants to stay in the hospital a few more days. Which intervention should the nurseimplement?•Schedule an appointment for an out-patient psychosocial assessment.70.An adult female client tells the nurse that though she is afraid her abusive boyfriendmight one day kill her, she keeps hoping that he will change. What action should thenurse take first?•Explore client’s readiness to discuss the situation.71.In caring for a client with Cushing syndrome, which serum laboratory value is mostimportant for the nurse to monitor?•Lactate•Glucose•Hemoglobin•Creatinine72.Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia andrecurrent chlamydia. What information is most important for the nurse to provide to thisclient?•Use two forms of contraception while taking this drug.73.A client in the emergency center demonstrates rapid speech, flight of ideas, and reportssleeping only three hours during the past 48h. Based on these finding, it is mostimportant for the nurse to review the laboratory value for which medication?•Divalproex.•Rationale: divalproex is the first line of treatment for bipolar disorder BPDbecause it has a high therapeutic index, few side effects, and a rapid onset incontrolling symptoms and preventing recurrent episodes of mania and depression.The serum value ofdivalproex should be determined since the client is exhibitingsymptoms of mania, which may indicate non-compliance with the medicationregimen.74.A male client who is admitted to the mental health unit for treatment of bipolar disorderhas a slightly slurred speech pattern and an unsteady gait. Which assessment finding ismost important for the nurse to report to the healthcare provider?

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•Serum lithium level of 1.6 mEq/L or mmol/l (SI)•Rationale: The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/L or mmol/l(SI). Slurred speech and ataxia are sign of lithium toxicity.75.A client was admitted to the cardiac observation unit 2 hours ago complaining of chestpain. On admission, the client’s EKG showed bradycardia, ST depression, but noventricular ectopy. The client suddenly reports a sharp increase in pain, telling thenurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q wavesand ST segment elevations in the anterior leads. What intervention should the nurseperform?•76.The nurse is developing a teaching program for the community. What populationcharacteristic is most influential when choosing strategies for implementing a teachingplan?•Literacy level77.A client is being discharged with a prescription for warfarin (Coumadin). Whatinstruction should the nurse provide this client regarding diet?•Eat approximated the same amount of leafy green vegetables daily so the amount ofvitamin Kconsumed is consistent.78.A client who had a small bowel resection acquired methicillin resistant staphylococcusaureus (MRSA) while hospitalized. He treated and released, but is readmitted todaybecause of diarrhea and dehydration. It is most important forthe nurse to implementwhich intervention.•Maintain contact transmission precaution79.A postoperative female client has a prescription for morphine sulfate 10 mg IVq3 hours for pain. One dose of morphine was administered when the client wasadmitted to the post anesthesia care unit (PACU) and 3 hours later, the client isagain complaining of pain. Her current respiratory rate is 8 breaths/minute. Whataction should the nurse take?•Administer Naxolone IV80.Which intervention is most important for the nurse to include in the plan of carefor an older woman with osteoporosis?•Place the client on fall precautions81.Based on the information provided in this client’s medical record during labor,which should the nurse implement? (Click on each chart tab for additionalinformation. Please be sure to scroll to the bottom right corner of each tab toview all information contained in the client’s medical record.)•Continue to monitor the progress of labor.Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min pernasal cannula.

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82.An unlicensed assistive personnel UAP leaves the unit without notifying thestaff. In what order should the unit manager implement this intervention toaddress the UAPs behavior? (Place the action in order from first on top to last onbottom.)1.Note date and time of the behavior.2.Discuss the issue privately with the UAP.3.Plan for scheduled break times.4.Evaluate the UAP for signs of improvement.83.A client with intestinal obstructions has a nasogastric tube to low intermittentsuction and is receiving an IV of lactated ringer’s at 100 ml/H. which finding ismost important for the nurse to report to the healthcare provider?•Serum potassium level of 3.1 mEq/L or mmol/L (SI)•Rationale:The normal potassium levelin the blood is 3.5-5.0 milliEquivalents per liter(mEq/L).84.Which type of Leukocyte is involved with allergic responses and the destructionof parasitic worms?•Neutrophils•Lymphocytes•Eosinophils•Monocytes•Rationale: Eosinophils are involved in allergic responses and destruction ofparasitic worms.85.The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6hours for a client with a postoperative wound infection. Which foods should thenurse encourage this client to eat?•Yogurt and/or buttermilk.86.Several months after a foot injury, and adult woman is diagnosed withneuropathic pain.The client describes the pain as severe and burning and is unable to put weight on herfoot. She asks the nurse when the pain will “finally go away.” How should the nurserespond?•Assist the client in developing a goal of managing the pain87.One day following an open reduction and internal fixation of a compoundfracture of the leg, a male client complains of “a tingly sensation” in his left foot.The nurse determines the client’s left pedal pulses are diminished. Based onthese finding, whatis the client’s greatest risk?•Neurovascular and circulation compromise related to compartment syndrome.88.The nurse is completing a head to be assessment for a client admitted forobservation after falling out of a tree. Which finding warrants immediateintervention by the nurse?•Clear fluid leaking from the nose.89.A client with multiple sclerosis (MS) has decreased motor function after taking ahot bath(Uhthoff’s sign). Which pathophysiological mechanism supports this response?

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•Temporary vasodilation90.While assessing a radial artery catheter, the client complains of numbness andpain distal to the insertion site. What interventions should the nurse implement?•Promptly remove the arterial catheter from the radial artery.91.A client is admitted with an epidural hematoma that resulted from askateboarding accident. To differentiate the vascular source of the intracranialbleeding, which finding should the nurse monitor?•Rapid onset of decreased level of consciousness.92.The nurse finds a client at 33 weeksgestation in cardiac arrest. What adaptationto cardiopulmonary resuscitation (CPR) should the nurse implement?•Position a firm wedge to support pelvis and thorax at 30 degree tilt.93.When preparing a client for discharge from the hospital following a cystectomyand a urinary diversion to treat bladder cancer, which instruction is mostimportant for the nurse to include in the client’s discharge teaching plan?•Report any signs of cloudy urine output.94.For the past 24 hours, an antidiarrheal agent, diphenoxylate, has beenadministered to a bedridden, older client with infectious gastroenteritis. Whichfinding requires the nurse to take further action?•Tented skin turgor.95.After repositioning an immobileclient, the nurse observes an area of hyperemia.To assess for blanching, what action should the nurse take?•Apply light pressure over the area.96.The nurse enters a client’s room and observes the client’s wrist restraint securedas seen in the picture. What action should the nurse take?•Reposition the restraint tie onto the bedframe.97.A female client with acute respiratory distress syndrome (ARDS) is chemicallyparalyzed and sedated while she is on as assist-control ventilator using 50%FIO2. Which assessment finding warrants immediate intervention by the nurse?•Diminished left lower lobe sounds•Rationale: Diminished lobe sounds indicate collapsed alveoli or tensionpneumothorax, which required immediate chest tube insertion to re-inflate the lung.98.The development of atherosclerosis is a process of sequential events. Arrange thepathophysiological events in orders of occurrence. (Place the first event on topand the last on the bottom)1.Arterial endothelium injury causes inflammation2.Macrophages consume low density lipoprotein (LDL), creatingfoam cells3.Foam cells release growth factors for smooth muscle cells4.Smooth muscle grows over fatty streaks creating fibrous plaques5.Vessel narrowing results in ischemia99.Following a motor vehicle collision, an adult female with a ruptured spleen and ablood pressure of 70/44, had an emergency splenectomy. Twelve hours after thesurgery, her urine output is 25 ml/hour for the last two hours. Whatpathophysiological reason supports the nurse’s decision to report this finding to

2023-2024 HESI RN Healthcare Exit Exam V1-V7 With Answers (893 Solved Questions) - Page 16 preview image

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the healthcare provider?•Oliguria signals tubular necrosis related tohypoperfusion100.A nurse-manager is preparing the curricula for a class for charge nurses. Astaffing formula based on what data ensures quality client care and is most cost-effective?•Skills of staff and client acuity101.When performing postural drainage on a client with Chronic ObstructivePulmonary Disease (COPD), which approach should the nurse use?•Explain that the client may beplaced in five positions102.A client presents in the emergency room with right-sided facial asymmetry. Thenurse asks the client to perform a series of movements that require use of thefacial muscles. What symptoms suggest that the client has most likely experiencea Bell’s palsy rather than a stroke?•Inability to close the affected eye, raise brow, or smile103.The nurse is teaching a client how to perform colostomy irrigations. Whenobserving the client’s return demonstration, which action indicated that theclientunderstood the teaching?•Keeps the irrigating container less than 18 inches above the stoma104.The nurse should teach the client to observe which precaution while takingdronedarone?•Avoid grapefruits and its juice105.A client who sustained a head injury following an automobile collision isadmitted to the hospital. The nurse include the client’s risk for developingincreased intracranial pressure (ICP) in the plan of care. Which signs indicate tothe nurse that ICP hasincreased?•Increased Glasgow coma scale score.•Nuchal rigidity and papilledema.•Confusion and papilledema•Periorbitalecchymosis.•Rationale: papilledema is always an indicator of increased ICP, and confusion isusually the first sign of increased ICP. Other options do not necessarily reflectincreased ICP.106.The nurse is caring for a client receiving continuous IV fluids through a singlelumen central venous catheter (CVC). Based on the CVC care bundle, whichaction should be completed daily to reduce the risk for infection?•Confirm the necessity for continued use of the CVC.107.During an annual physical examination, an older woman’s fasting blood sugar(FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additionalfinding obtained during afollow-up visit 2 weeks later is most indicative that theclient has diabetes mellitus (DM)?•Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).108.A new mother tells the nurse that she is unsure if she will be able to transitioninto parenthood. What action should the nurse take?•Determine if she can ask for support from family, friend, or the baby’s father.

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