Exam (elaborations) - hesi rn exit exam v4 full 160 answers
1. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value only.) 200ml . 2...
1. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for
eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value only.) 200ml . 25 ml of
full strength feeding mixed with 25ml of water provided 50ml of half strength. 25ml × 8 hours= 200m
2.An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? Apply an
external condom catheter
3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses
to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed
for prayer. What action should the nurse implement? Reschedule administration of the antibiotic until after he
completes his prayers
4.UAP using a hand sanitzers that is alcohol for 2 minutes- tell that hand sanitizer use is less > 2min
5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The child
weighs 44 pounds. How many mg of the medication should the nurse administer. Answer: 800 Rationale: First,
convert the child’s weight to kg: 44 pounds divided by
2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg
6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather
than trickles from the vagina. The uterine fundus is firm and the client’s vital signs are pulse 88 beats/minute;
respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take next?
Compare current vital signs with previous vital signs
7. A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye.
Which action should the school nurse take? Have the parent take the child for emergency help
8. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre behavior,
and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis
of “Altered thought processes, secondary to” what condition? Postpartum psychosis
9. The nurse identifies a priority diagnosis of, “Altered comfort related to menstrual cramps” for a 25-year-old
female client. Which self-care activity should the nurse emphasize in the client’s teaching plan? Regular
aerobic exercise.
10. Psych/Alcohol/Tylenol overdose antidote – Give Mucomyst
11. Medical Surgical/Laxative abuses – Patient -taking Milk of Magnesium
12. Spiritual/Documentation- Native American – Allow pt’s family to stay in the room
, 13. Leadership- Interpreter informed consent – Pt should sign the consent
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