HESI Others Exit Exam With Answers (656 Solved Questions)

Preview (16 of 204 Pages)

100%

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 1 preview image

Loading page ...

799 RN Exit ExamTerms in this set (798)Following discharge teaching, a male client with duodenal ulcer tells the nurse the hewill drink plenty of dairy products, such as milk, to help coat and protect his ulcer. Whatis the best follow-up action by the nurse?a. Remind the client that it is also important to switch to decaffeinated coffee and tea.b. Suggest that the client also plan to eat frequent small meals to reduce discomfortc. Review with the client the need to avoid foods that are rich in milk and cream.d. Reinforce this teaching by asking the client to list a dairy food that he might select.Review with the client the need to avoid foods that are rich in milk and creamRationale: Diets rich in milk and cream stimulate gastric acid secretion and should beavoided.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 medicationbecause the drugs make him "feel bad". In explaining the need for hypertension control,the nurse should stress that an elevated BP places the client at risk for whichpathophysiological condition?a. Blindness secondary to cataractsb. Acute kidney injury due to glomerular damagec. Stroke secondary to hemorrhaged. Heart block due to myocardial damageStroke secondary to hemorrhageRationale: Stroke related to cerebral hemorrhage is major risk for uncontrolledhypertension.The nurse observes an unlicensed assistive personnel (UAP) positioning a newlyadmitted client who has a seizure disorder. The client is supine and the UAP is placingsoft pillows along the side rails. What action should the nurse implement?a. Ensure that the UAP has placed the pillows effectively to protect the client.b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.c. Assume responsibility for placing the pillows while the UAP completes another task.d. Ask the UAP to use some of the pillows to prop the client in a side lying position.lOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 2 preview image

Loading page ...

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 3 preview image

Loading page ...

Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillowsRationale: The nurse should instruct the UAP to pad the side rails with soft blankestbecause the use of pillows could result in suffocation and would need to be removed atthe onset of the seizure. The nurse can delegate paddling the side rails to the UAPAn adolescent with major depressive disorder has been taking duloxetine (Cymbalta) forthe past 12 days. Which assessment finding requires immediate follow-upa. Describes life without purposeb. Complains of nausea and loss of appetitec. States is often fatigued and drowsyd. Exhibits an increase in sweating.Describes life without purposeRationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor thatis known to increase the risk of suicidal thinking in adolescents and young adults withmajor depressive disorder. B, C and D are side effectsA 60-year-old female client with a positive family history of ovarian cancer hasdeveloped an abdominal mass and is being evaluated for possible ovarian cancer. HerPapanicolau (Pap) smear results are negative. What information should the nurseinclude in the client's teaching plana. Further evaluation involving surgery may be neededb. A pelvic exam is also needed before cancer is ruled outc. Pap smear evaluation should be continued every six monthd. One additional negative pap smear in six months is needed.Further evaluation involving surgery may be neededRationale: An abdominal mass in a client with a family history for ovarian cancer shouldbe evaluated carefullyA client who recently underwent a tracheostomy is being prepared for discharge tohome. Which instructions is most important for the nurse to include in the dischargeplan?a. Explain how to use communication tools.b. Teach tracheal suctioning techniquesc. Encourage self-care and independence.d. Demonstrate how to clean tracheostomy site.Teach tracheal suctioning techniquesRationale: Suctioning helps to clear secretions and maintain an open airway, which iscritical.In assessing an adult client with a partial rebreather mask, the nurse notes that theoxygen reservoir bag does not deflate completely during inspiration and the client'srespiratory rate is 14 breaths / minute. What action should the nurse implementlOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 4 preview image

Loading page ...

a. Encourage the client to take deep breathsb. Remove the mask to deflate the bagc. Increase the liter flow of oxygend. Document the assessment dataDocument the assessment dataRational: reservoir bag should not deflate completely during inspiration and the client'srespiratory rate is within normal limits.During shift report, the central electrocardiogram (EKG) monitoring system alarms.Which client alarm should the nurse investigate first?a. Respiratory apnea of 30 secondsb. Oxygen saturation rate of 88%c. Eight premature ventricular beats every minuted. Disconnected monitor signal for the last 6 minutes.Respiratory apnea of 30 secondsRationale: The priority is the client whose alarm indicating respiratory apnea that shouldbe assessed first.During a home visit, the nurse observed an elderly client with diabetes slip and fall.What action should the nurse take first?a. Give the client 4 ounces of orange juiceb. Call 911 to summon emergency assistancec. Check the client for lacerations or fracturesd. Asses clients blood sugar levelCheck the client for lacerations or fracturesRationale: After the client falls, the nurse should immediately assess for the possibility ofinjuries and provide first aid as neededAt 0600 while admitting a woman for a schedule repeat cesarean section (C-Section),the client tells the nurse that she drank a cup a coffee at 0400 because she wanted toavoid getting a headache. Which action should the nurse take first?a. Ensure preoperative lab results are availableb. Start prescribed IV with lactated Ringer'sc. Inform the anesthesia care providerd. Contact the client's obstetrician.Inform the anesthesia care providerRationale: Surgical preoperative instruction includes NPO after midnight the day ofsurgery to decrease the risk of aspiration should vomiting occur during anesthesia.While it is possible the C-section will be done on schedule or rescheduled for later in theday, the anesthesia provider should be notified first.After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2heart sounds. To determine if an S3 heart sound is present, what action should thelOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 5 preview image

Loading page ...

nurse take firsta. Side the stethoscope across the sternum.b. Move the stethoscope to the mitral sitec. Listen with the bell at the same locationd. Observe the cardiac telemetry monitorListen with the bell at the same locationRationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds suchas S3 and S4. The nurse listens at the same site using the diaphragm the diaphragmand bell before moving systematically to the next sites.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?a. Woman, Infant, and Children programb. Medicaidc. Medicared. Consolidated Omnibus Budget Reconciliation Act provision.MedicareRationale: Title XVII of the social security Act of 1965 created Medicare Program toprovide medical insurance for person more than 65 years or older, disable or withpermeant kidney failure, WIC provides supplemental nutrition to meet the needs ofpregnant of breastfeeding woman, infants and children up to age of 6. Medicaidprovides financial assistance to pay for medical services for poor older adults, blind,disable and families with dependent children. COBRA(D) health benefit provisions is alimited insurance plan for those who has been laid off or become unemployed.Upgrade to remove adsOnly $35.99/yearA 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?a. Fruit-flavored yogurt.b. Cheese and crackers.c. Cold cereal with skim milk.d. Toasted wheat bread and jellyToasted wheat bread and jellyRationale: Dairy products decrease the effect of tetracycline, so the nurse instructs theclient to eat a snack such as toast, which contains no dairy products and may decreaseGI symptoms.Following a lumbar puncture, a client voices several complaints. What complaintindicated to the nurse that the client is experiencing a complication?a. "I am having pain in my lower back when I move my legs"lOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 6 preview image

Loading page ...

b. "My throat hurts when I swallow"c. "I feel sick to my stomach and am going to throw up"d. I have a headache that gets worse when I sit up""I have a headache that gets worse when I sit up"Rationale: A post-lumbar puncture headache, ranging from mild to severe, may occur asa result of leakage of cerebrospinal fluid at the puncture site. This complication isusually managed by bedrest, analgesic, and hydration.An elderly client seems confused and reports the onset of nausea, dysuria, and urgencywith incontinence. Which action should the nurse implementa. Auscultate for renal bruitsb. Obtain a clean catch mid-stream specimenc. Use a dipstick to measure for urinary ketoned. Begin to strain the client's urine.Obtain a clean catch mid-stream specimenRationale: This elderly is experiencing symptoms of urinary tract infection. The nurseshould obtain a clean catch mid-stream specimen to determine the causative agent soan anti-infective agent can be prescribed.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 are contraindicatedfor this child?a. Wheat productsb. Foods sweetened with aspartame.c. High fat foodsd. High calories foods.Foods sweetened with aspartameRationale: Aspartame should not be consumed by a child with PKU because ut isconverted to phenylalanine in the body. Additionally, milk and milk products arecontraindicated for children with PKU.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?a. Ask a more experience nurse to perform that scrub since it is the first time of the dayb. Validate the nurse is implementing the OR policy for surgical hand scrubc. Inform the nurse that hand scrubs should be 3 minutes between cases.d. Direct the nurse to continue the surgical hand scrub for a 5-minute duration.Direct the nurse to continue the surgical hand scrub for a 5 minute durationRationale: The surgical hand scrub should last for 5 to 10 mints, so the nurse should bedirected to continue the vigorous scrub using a reliable agent for the total duration of 5mints. It is not necessary to reassign staff (A). The length of the hand scrub andlOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 7 preview image

Loading page ...

subsequent scrubs during the day require the same process for the same amount oftime, (B and C)Which breakfast selection indicates that the client understands the nurse's instructionsabout the dietary management of osteoporosis?a. Egg whites, toast and coffee.b. Bran muffin, mixed fruits, and orange juice.c. Granola and grapefruit juiced. Bagel with jelly and skim milk.Bagel with jelly and skim milkRationale: D includes dairy products which contain calcium and does not include anyfoods that inhibit calcium absorption. The primary dietary implication of osteoporosis isthe need for increased calcium and reduction in foods that decrease calcium absorption,such as caffeine and excessive fiber.The charge nurse of critical care unit informed at beginning of shift that less thanoptimal number registered nurses be working that shift. In planning assignments, whichclient should receive most care hours by a registered nursea. A 34 yo admitted today after emergency appendendectomy who has peripheralintravenous catheter, Foley catheter.b. A 48 yo marathon runner w/a central venous catheter experiencing nausea, vomitingdue to electrolyte disturbance following a race.c. A 63 yo chain smoker w/ chronic bronchitis receiving O2 nasal cannula and a saline-locked peripheral intravenous catheter.d. An 82 yo client with Alzheimer's disease newly-fractures femur w/Foley catheter andsoft wrist restrains appliedAn 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foleycatheter and soft wrist restrains appliedRationale: (D) describe the client at the most risk for injury and complications becauseof the factor listed. (A) has complete the recovery period form anesthesia but requirescritical care because of the invasive lines and new abdominal incision. (B) is likely to bein excellent physical condition and has one invasive line needed for rehydration. (C) isessentially stable, despite having a chronic condition.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 theshoe and pierced the bottom of the child's foot. Which action should the nurseimplement first?a. Cleanse the foot with soap and water and apply an antibiotic ointmentb. Provide teaching about the need for a tetanus booster within the next 72 hours.c. have the mother check the child's temperature q4h for the next 24 hoursd. transfer the child to the emergency department to receive a gamma globulin injectionlOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 8 preview image

Loading page ...

Cleanse the foot with soap and water and apply an antibiotic ointmentRationale: The nurse should cleanse the wound first and implement B next.The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I havebeen applying triple antibiotic ointment for two days, but there has been noimprovement." What instruction should the nurse provide?a. Antibiotics take two weeks to become effective against infections such as athlete'sfoot.b. Continue using the ointment for a full week, even after the symptoms disappear.c. Applying too much ointment can deter its effectiveness. Apply a thin layer to preventmaceration.d. Stop using the ointment and encourage complete drying of the feet and wearingclean socks.Stop using the ointment and encourage complete drying of the feet and wearing cleansocks.Rationale: Athlete's foot (tinea pedi) is a fungal infection that afflicts the feet and causesscaliness and cracking of the skin between the toes and on the soles of the feet. Thefeet should be ventilated, dried well after bathing, and clean socks should be placed onthe feet after bathing. Antifungal ointments may be prescribed, but antibiotic ointmentsare not useful.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 experiencesa. Palpitations and shortness of breathb. Bradycardia and constipationc. Lethargy and lack of appetited. Muscle cramping and dry, flushed skinPalpitations and shortness of breathRationale: An overdose of thyroid preparation generally manifests symptoms of anagitated state such as tremors, palpitations, shortness of breath, tachycardia, increasedappetite, agitation, sweating and diarrhea.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?a. Determine the client's level of orientation and cognitionb. Assess distal pulses and signs of peripheral edemac. Obtain a list of medications taken for cardiac history.d. Ask the client about exposure to environmental heat.Obtain a list of medications taken for cardiac historylOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 9 preview image

Loading page ...

Rationale: The client is presenting with signs of digitalis toxicity. A list of medication,which is likely to include digoxin (Lanoxin) for heart failure, can direct furtherassessment in validating digitalis toxicity with serum labels greater than 2 mg/ml that iscontributing to client's presenting clinical picture.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 deliverhow many ml/hour? (Enter numeric value only.)7575Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcgx 250 ml = 3/1 x 25 = 75 ml/hourThe pathophysiological mechanism are responsible for ascites related to liver failure?(Select all that apply)a. Bleeding that results from a decreased production of the body's clotting factorsb. Fluid shifts from intravascular to interstitial area due to decreased serum proteinc. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomend. Increased circulating aldosterone levels that increase sodium and water retentione. Decreased absorption of fatty acids in the duodenum leading to abdominal distention.b. Fluid shifts from intravascular to interstitial area due to decreased serum proteinc. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomend. Increased circulating aldosterone levels that increase sodium and water retentionRationale: When liver fail production of albumin is reduced. Since albumin is the primaryserum protein creating intravascular osmotic pressure, decreased serum protein allowsa fluids shift into the interstitial space. Pressure increases in the portal circulation ©when venous return from the upper GI tract cannot flow freely into sclerosed liver, whichcause a pressure gradient to further Increase fluid shifts into the abdomen. A failing liverineffectively inactivates steroidal hormones, such as aldosterone resulting in sodiumand water retention.The nurse is auscultating a client's heart sounds. Which description should the nurseuse to document this sound? (Please listen to the audio first to select the option thatapplies)a. S1 S2b. S1 S2 S3c. Murmurd. Pericardial friction rub.MurmurRationale: A murmur is auscultated as a swishing sound that is associated with theblood turbulence created by the heart or valvular defect. B is associate with HeartFailure.lOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 10 preview image

Loading page ...

The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for aninfant. The 500 mg 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 eachdose? (Enter numeric value only. If rounding is required, round to the nearest tenth.0.40.4rationale: 35mg/100mg x 1 = 0.35 = 0.4 mlThe 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?a. Auscultate the client's bowel soundsb. Observe for edema around the anklesc. Measure the client's capillary glucose leveld. Count the apical and radial pulses simultaneouslyAuscultate the client's bowel soundsRationale: hydromorphone is a potent opioid analgesic that slows peristalsis andfrequently causes constipation, so it is most important to Auscultate the client's bowelsoundsA 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 client to discuss "do not resuscitate" with her healthcare providerA 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?a. Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hourb. Continue the full strength feeding after decreasing the rate of infusion to 25 ml/hr.c. Maintain the present feeding until diarrhea subsides and the begin the next newprescription.d. Withhold any further feeding until clarifying the prescription with healthcare provides.Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hourRationale: Diluting the formula can help alleviate the diarrhea. Diarrhea can occur as acomplication of enteral tube feeding and can be due to a variety of causes includinghyperosmolar formula.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?a. "Is there a history of female baldness in your family?"lOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 11 preview image

Loading page ...

b. "Are you under any unusual stress at home or work?"c. "Do you work with hazardous chemicals?"d. "Have you noticed any changes in your fingernails?"Have you noticed any changes in your fingernails?Rationale: The pattern of reported manifestations is suggestive of hypothyroidismAfter a third hospitalization 6 months ago, a client is admitted to the hospital with ascitesand malnutrition. The client is drowsy but responding to verbal stimuli and reportsrecently spitting up blood. What assessment finding warrants immediate intervention bythe nurse?a. Bruises on arms and legsb. Round and tight abdomenc. Pitting edema in lower legsd. Capillary refill of 8 secondsCapillary refill of 8 secondsRationale: The client is bleeding and hypovolemia is likely. Capillary refill is greater than3 to 5 seconds indicates poor perfusion and requires immediate attentionUpgrade to remove adsOnly $35.99/yearAfter 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)a. The client voluntarily grants permission for the procedure to be doneb. The surgeon has explained to the client why the surgery is necessary.c. The client is competent to sign the consent without impairment of judgmentd. The client understands the risks and benefits associated with the proceduree. After considering alternatives to surgery, the client elects to have the procedure.a. The client voluntarily grants permission for the procedure to be donec. The client is competent to sign the consent without impairment of judgmentd. The client understands the risks and benefits associated with the procedureRationale: Inform consent is required for any invasive procedure. The nurse's signatureas a witness to the client's signature on surgical consent indicates that the clientvoluntary gives consent for the scheduled procedure. C is competent to give consent,and D and understand the risk and benefits of the procedure.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?a. Ask the client to explain why he constantly request the nurselOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 12 preview image

Loading page ...

b. Encourage the client to verbalize his feelings about the nursec. Reassure the client that his request will be met whenever possible.d. Advise the client that assignments are not based on client requestsAdvise the client that assignments are not based on clients requestsRationale: Those with antisocial personality disorders are manipulative in order to meettheir own needs. The charge nurse must set limits on this behavior. The client'ssuperficial charm and emotional maturity prevent effective therapeutic communicationand (A and B) will be used to the client's advantage. C encourage further manipulativebehavior.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?a. Call the radiology departmentb. Reinsert the implant into the vaginac. Apply double gloves to retrieve the implant for disposal.d. Place the implant in a lead container using long-handled forcepsPlace the implant in a lead container using long-handled forcepsRationale: Solid or sealed radiation sources, such as Cesium which is removed aftertreatment, are inserted into an applicator or cervical implant to emit continuous, lowenergy radiation for adjacent tumor tissues. If the radiation source or the applicatorbecome dislodged long-handled forceps should be used to retrieve the radiation implantto prevent injury due to direct handling. The applicator is then placed in the leadcontainer.The client with which type of wound is most likely to need immediate intervention by thenurse?a. Lacerationb. Abrasionc. Contusiond. UlcerationLacerationRationale: A laceration is a wound that is produced by the tearing of soft body tissue.This type of wound is often irregular and jagged. A laceration wound is oftencontaminated with bacteria and debris from whatever object caused the cutThe 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?a. Record urine output every hourb. Monitor blood pressure frequentlyc. Evaluate neurological statusd. Maintain seizure precautionslOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 13 preview image

Loading page ...

Monitor blood pressure frequentlyRationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that mayprecipitate life-threatening hypertensionWhen caring for a client who has acute respiratory distress syndrome (ARDS), thenurse elevates the head of the bed 30 degrees. What is the reason for this intervention?a. To reduce abdominal pressure on the diaphragmb. to promote retraction of the intercostal accessory muscle of respirationc. to promote bronchodilation and effective airway clearanced. to decrease pressure on the medullary center which stimulates breathingTo reduce abdominal pressure on the diaphragmRationale: a semi-sitting position is the best position for matching ventilation andperfusion and for decreasing abdominal pressure on the diaphragm, so that the clientcan maximize breathingWhen assessing a mildly obese 35-year-old female client, the nurse is unable to locatethe gallbladder 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?a. The client is too obeseb. Palpating in the wrong abdominal quadrantc. The gallbladder is normald. Deeper palpation technique is neededThe gallbladder is normalRationale: a normal healthy gallbladder is not palpableA 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. Sinceshe is breastfeeding, she stopped taking her antianxiety medications, but thinks shemay need to start taking them again because of her increased anxiety. What responseis best for the nurse to provide this woman?a. Describe the transmission of drugs to the infant through breast milkb. Encourage her to use stress relieving alternatives, such as deep breathing exercisesc. Inform her that some antianxiety medications are safe to take while breastfeedingd. Explain that anxiety is a normal response for the mother of a 3-week-old.Inform her that some antianxiety medications are safe to take while breastfeedingRationale: There are several antianxiety medications that are not contraindicated forbreastfeeding mothers. The woman is apparently aware that drugs can be transmittedthrough breast milk, so A is not helpful. C might be helpful, but the client's historysuggest that nonpharmacological methods of anxiety management do not produce thebest outcome. (D) the mother's history places her at risk for severe anxiety.lOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 14 preview image

Loading page ...

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?a. obtain a serum potassium levelb. administer the client's usual dose of insulinc. assess pupillary response to lightd. Start an intravenous (IV) infusion of normal salineStart an intravenous (IV) infusion of normal salineRationale: the nurse should first start an intravenous infusion of normal saline to replacethe fluids and electrolytes because the client has been vomiting, and it is unclear whenhe last ate or took insulin. The symptoms of confusion, lethargy, vomiting, andabdominal cramping are all suggestive of hyperglycemia, which also contributes todiuresis and fluid electrolyte imbalance.A client who received multiple antihypertensive medications experiences syncope dueto a drop in blood pressure to 70/40. What is the rationale for the nurse's decision tohold the client's scheduled antihypertensive medication?a. Increased urinary clearance of the multiple medications has produced diuresis andlowered the blood pressureb. The antagonistic interaction among the various blood pressure medications hasreduced their effectivenessc. The additive effect of multiple medications has caused the blood pressure to drop toolow.d. The synergistic effect of the multiple medications has resulted in drug toxicity andresulting hypotension.The additive effect of multiple medications has caused the blood pressure to drop toolowRationale: When medication with a similar action are administered, an additive effectoccurs that is the sum of the effects of each of the medication. In this case, severalmedications that all lower the blood pressure, when administer together, resulted inhypotension.Which client is at the greatest risk for developing delirium?a. An adult client who cannot sleep due to constant pain.b. an older client who attempted 1 month agoc. a young adult who takes antipsychotic medications twice a dayd. a middle-aged woman who uses a tank for supplemental oxygenAn adult client who cannot sleep due to constant pain.Rationale: Client who are in constant pain ad have difficulty sleeping or resting are atlOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 15 preview image

Loading page ...

high risk for delirium. Supplemental oxygen may cause confusion. B is takingmedication so is not at high risk of delirium.Which intervention should the nurse include in a long-term plan of care for a client withChronic Obstructive Pulmonary Disease (COPD)?a. Reduce risks factors for infectionb. Administer high flow oxygen during sleepc. Limit fluid intake to reduce secretionsd. Use diaphragmatic breathing to achieve better exhalationReduce risks factors for infectionRationale: Interventions aimed at reducing the risk factors of infections should beincluded in the plan of care COPD client are at particular risk for respiratory infection.Prevention and early detection of infections are necessary.Which location should the nurse choose as the best for beginning a screening programfor hypothyroidism?a. A business and professional women's group.b. An African-American senior citizens centerc. A daycare center in a Hispanic neighborhoodd. An after-school center for Native-American teensA business and professional women's groupRationale: The population at highest risk is A so this is the group that would benefit themost for a screening program of hypothyroidism and occurs between 35 and 60 years ofage and is most common in females.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 most important for the nurse to implement?a. Measure vital signsb. Auscultate breath soundsc. Palpate the abdomend. Observe the skin for bruisingMeasure vital signsRationale: Abrupt withdrawal of an exogenous corticosteroids can precipitate adrenalinsufficiency and hypoglycemia, hypokalemia, and circulatory collapse can occur. Ismost important for the nurse to assess vital sign to impending shock.A male client reports the onset of numbness and tingling in his fingers and around hismouth. Which lab is important for the nurse to review before contacting the health careprovider?a. capillary glucoseb. urine specific gravitylOMoARcPSD|12029159

HESI Others Exit Exam With Answers (656 Solved Questions) - Page 16 preview image

Loading page ...

c. Serum calciumd. white blood cell countSerum calciumRationale: Numbness and tingling of the fingers and around the mouth, along withmuscle cramps are signs of hypocalcemiaWhat explanation is best for the nurse to provide a client who asks the purpose of usingthe log-rolling technique for turning?a. working together can decrease the risk for back injuryb. The technique is intended to maintain straight spinal alignment.c. Using two or three people increases client safety.d. turning instead of pulling reduces the likelihood of skin damageThe technique is intended to maintain straight spinal alignment.Rationale: The main rationale for use of the long-rolling technique is to maintain theclient's spine straight alignment.A client receiving chemotherapy has severe neutropenia. Which snack is best for thenurse to recommend to the client?a. Plain yogurt with sweetened with raw honeyb. Peanuts in the shell, roasted or un-roasted.c. Aged farmer's cheese with celery sticksd. Baked apples topped with dried raisinsBaked apples topped with dried raisinsRationale: A patient with chemotherapy-induced severe neutropenia is at high risk forinfection. A low bacteria diet is required D is a healthy snack for a client receivingchemotherapy. A, B and C have a high bacterial count and should be avoided.Which action should the school nurse take first when conducting a screening forscoliosis?a. Compare dorsal measurement of trunkb. Extend arms over head for visualizationc. Inspect for symmetrical shoulder height.d. Observe weight-bearing on each leg.Inspect for symmetrical shoulder height.Rationale: Children between 9 and 15 years old should be screening for scoliosis, whichis exhibited.... Vertebral column. Screening for scoliosis should begin with inspection ofshoulder heightAn Unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports tothe charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. Whataction should the charge nurse implement?lOMoARcPSD|12029159

Preview Mode

This document has 204 pages. Sign in to access the full document!

Report

Study Now!

Document Details

Related Documents

Nursing School Entrance Exams: HESI A2 / NLN PAX-RN / PSB-RN / RNEE / TEAS, 6th Edition (2020)

HESI Evolve Leadership/Management Practice Exam with Answers (114 Solved Questions)

HESI Comprehensive Medical Surgical Exit Exam with Answers (839 Solved Questions)

2024 HESI Mental Health Actual Exam With Answers (151 Solved Questions)

2023-2024 HESI RN Pharmacology Actual Exam With Answers (180 Solved Questions)

HESI Pharmacology Practice Exam With Answers (102 Solved Questions)

HESI Mental Health Exit Exam With Answers (58 Solved Questions)

HESI Fundamentals Proctored Exam With Answers (6 Solved Questions)

2023 HESI Grammer A2 Exam With Answers (41 Solved Questions)

HESI Grammar A2 Exam Testbank With Answers (50 Solved Questions)

Company

Explore

Study Tools