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HESI_Exit_Exam_2. TEST 2 155 QUESTIONS AND 100% CORRECT ANSWERS IN THE LAST PAGE.
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Name: Class: Date: ID: AHESI_Exit_Exam_2. TEST 2 155 QUESTIONS AND 100% CORRECT ANSWERS IN THE
LAST PAGE.
TEST 2
Multiple Choice
Identify the letter of the choice that best completes the statement or answers the question.
1. The nurse should question a prescription for docusate sodium (Colace) for a client with which
problem?
a. First day post myocardial infarction.
b. Two days following a knee replacement.
c. Abdominal pain of unknown etiology.
d. History of liver disease.
2. The nurse working on a medical unit is assigned to care for four clients. Which client should
the nurse assess first?
a. A client who is quadriplegic and is complaining of a severe headache.
b. A client who had a stroke and now has right-sided weakness.
c. A client who has a pressure ulcer and now has a temperature of 102.3° F.
d. An elderly client who is requesting medication for constipation.
3. A male client is accompanied to the emergency department by the police after trying to jump
off a bridge. As the nurse begins the initial evaluation, what is the priority assessment?
a. Assess to see if the client is having command hallucinations.
b. Determine where the client usually seeks healthcare treatment.
c. Assess if the client has a history of aggression.
d. Determine if the client has a history of depression.
4. Prior to discharge, the parents of a child with cystic fibrosis are demonstrating chest
physiotherapy (CPT) that they will perform for their child at home. Which action requires
intervention by the nurse?
a. A bronchodilator is administered before starting CPT.
b. The child is placed in a supine position to begin percussions.
c. A cupped hand is used when percussing the lung fields.
d. Plan to perform CPT when the child awakens in the morning.
5. A client at 29-weeks gestation is receiving magnesium sulfate 3 grams/hour for pre-term labor.
After administering the loading dose, what assessment finding should the nurse report to the
healthcare provider immediately?
a. A decrease in respirations from 20 to 17 breaths/minute.
b. An increase in temperature from 98.9° to 99.9° F.
c. An increase in blood pressure from 110/65 to 120/85.
d. A decrease in deep tendon reflexes from 3+ to 1+.
6. Based on the change of shift report, the client with which signs and symptoms should be
assessed by the nurse first?
a. Epigastric pain, no bowel sounds.
b. Chest pressure, diaphoresis, nausea.
c. Chest tightness, wheezing, coughing.
d. Calf pain, positive Homan's sign.
1
,Name: ID: A
7. A client who is diaphoretic and talking incoherently presents in the emergency department
triage area. What assessment should the triage nurse obtain first?
a. A finger-stick glucose.
b. A blood pressure.
c. Temperature
d. Arterial blood gases.
8. A 59-year-old male client is brought to the emergency room where he is assessed to have a
Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the
client's condition?
a. He is in a coma, and has a very poor prognosis.
b. This client is conscious, but is not oriented to time and place.
c. He has a good prognosis for recovery.
d. The client has increased intracranial pressure.
9. Three days postoperative, a client's wound drainage changes in appearance from sanguineous
to serous. Based on this finding, what nursing intervention should the nurse implement?
a. Continue to monitor the wound.
b. Monitor the client's vital signs.
c. Apply pressure to the wound.
d. Obtain a wound culture.
10. A client with heart failure has developed a large pleural effusion and the healthcare provider
plans to perform a thoracentesis. In preparing the client for this procedure, what intervention
should the nurse implement?
a. Notify the operating room personnel to schedule the procedure.
b. Contact the client's next of kin to sign the operative consent.
c. Determine if the client is allergic to antibiotics.
d. Instruct the client to remain immobile during the procedure.
11. A young adult male client is admitted to the emergency room with a bleeding abdominal
wound following a motor vehicle collision. He is crying out with pain. His friends report that
he often uses cocaine. What nursing diagnosis has the greatest priority?
a. High risk for injury related to cocaine withdrawal.
b. High risk for injury related to hemorrhage.
c. Pain related to injuries.
d. Anxiety related to trauma of motor vehicle accident.
12. Which action should the nurse take first when performing tracheostomy care?
a. Cleanse around the stoma.
b. Suction the tracheostomy.
c. Oxygenate with 100% oxygen.
d. Secure the new neck strap.
13. Which assessment finding would indicate to the nurse the need for intramuscular
administration of vitamin K to a client with cirrhosis?
a. Hemoccult positive stool.
b. Anorexia and nausea.
c. Increasing ascites.
d. Decreased level of consciousness.
2
,Name: ID: A
14. Prior to removing the upper plate of a confused client to perform denture care, which action
should the nurse take?
a. Scrub the dentures with a foam swab.
b. Move the plate up and down slightly.
c. Fill the denture cup with hot water.
d. Carefully insert an oral airway.
15. A 45-year-old female client who had a hysterectomy one week ago asks the nurse when she will
start to experience hot flashes. Before responding to the client's question, what information
should the nurse obtain?
a. The reason why the hysterectomy was performed.
b. The type of birth control used preoperatively.
c. Whether the client's ovaries were also removed.
d. The type of hysterectomy that was performed.
16. A 68-year-old male client is admitted to the medical unit, and one of his nursing diagnoses is,
"Altered urinary elimination." The nurse knows that acute renal failure may be due to a
variety of causes that can be classified as prerenal, renal, and postrenal. What is an example
of a causative factor that is classified as "renal?"
a. Hemorrhage from a chest wound.
b. Malignancy of the kidneys.
c. Renal calculi blocking the ureters.
d. Benign prostatic hypertrophy.
17. When developing a teaching plan on tuberculosis, which information would be accurate for the
nurse to include?
a. Those with a positive tuberculin test can expect to eventually develop active
tuberculosis.
b. Isoniazid (INH) is the drug of choice for prevention therapy.
c. A slightly elevated temperature at mid-morning is a cardinal sign of tuberculosis.
d. A tuberculin skin test should be read 24 hours after administration.
18. Following a vaginal delivery, a postpartum client complains of severe cramping after
breastfeeding her newborn. Which explanation describes the most likely reason for the client's
pain?
a. A retained placenta.
b. Problems with the process of involution.
c. The release of oxytocin hormone.
d. A possible ileus.
19. What nursing diagnosis has the highest priority for a client with severe ascites as a result of
liver disease?
a. Sleep pattern disturbance.
b. Body image disturbance.
c. Ineffective breathing pattern.
d. Fear of dying.
3
, Name: ID: A
20. The nurse obtains a blood sample from a gravid client for determination of alpha-fetoprotein
(AFP). What information will this laboratory value provide?
a. Determination of the existence of spina bifida.
b. Screening for possible neural tube defects.
c. Determination of fetal lung maturity.
d. Screening for Tay-Sachs disease.
21. A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and
foot care. Which statement by the client indicates to the nurse that effective learning has
occurred?
a. "I will use my swimming pool early in the day while the water is still very cool."
b. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling."
c. "I will try to keep moving if leg pain occurs to help promote good circulation."
d. "I can use a mirror to check the bottoms of my feet for any signs of breakdown."
22. A 14-year-old male client arrives at the emergency room in status epilepticus. He was
diagnosed with a seizure disorder in childhood. What is the most likely cause of his present
condition?
a. Increasing intracranial pressure.
b. Acute withdrawal from anticonvulsant medication.
c. A closed head injury.
d. A central nervous system infection.
23. A 75-year-old female client had a total hip replacement two days ago. She has never been in
the hospital before. She has just called for the bedpan. How should the nurse place the pan
under this client?
a. Ask her to grab her overbed trapeze, push both heels into the mattress, and raise
her buttocks off the bed so the bedpan can be slipped under her.
b. Ask her to roll to the unoperated side and slide the bedpan under her, then roll her
back onto the pan.
c. Ask her to roll to the operated side and slide the bedpan under her, then roll her
back onto the pan.
d. Ask her to flex her knees, spread her legs, and lift her buttocks with the flat part
of her feet, then push the bedpan under her from the front.
24. In caring for a client who is receiving peritoneal dialysis, the nurse should be alert for what
complications?
a. Abdominal pain, tenderness, and rigidity.
b. Clear dialysate drainage and burning on urination.
c. An occluded vascular access device and flank pain.
d. Increased serum albumin level, decreased BUN, and increased hematocrit.
25. A nurse seeks to alter a provision of a state's Nurse Practice Act regarding nurse-client ratios,
which the nurse believes to be unsafe. What action is most likely to impact a ruling by the
state's Board of Nursing?
a. Send an anonymous letter of concern to the local newspaper.
b. Meet with the nurse's representative to the state legislature.
c. Send documentation of the problem to the American Nurses' Association.
d. File a grievance at the medical center where the nurse is employed.
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