Exam (elaborations)
HESI Exit V2
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Exam of 85 pages for the course HESI Exit V2 at HESI Exit V2 (HESI Exit V2)
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HESI Exit V21. The nurse knows that which statement by the mother indicates that themother
understands safety precautions with her four month-old infant and her 4year-old
child?
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on ablanket to
play with my 4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocksstuck up in
the air
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old abottle in
the kitchen
while I make supper."
The correct answer is D: "I have the four year-old hold andhelp
feed the four month-old a bottle in the kitchen
2. Upon completing the admission documents, the nurse learns that the87 year-old
client
does not have an advance directive. What action should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary
The correct answer is B: Give information about advance
directives
3. A nurse administers the influenza vaccine to a client in a clinic. Within15 minutes
after
the immunization was given, the client complains of itchy and wateryeyes, increased
anxiety, and difficulty breathing. The nurse expects that the first action inthe sequence
of
care for this client will be to
,A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
The correct answer is B: Administer epinephrine 1:1000 asordered .
,4. Which of these children at the site of a disaster at a child day carecenter would
the
triage nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel betweencrying
episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper leg
fracture
D) A school-age child with singed eyebrows and hair on the armsThe
correct answer is B: A toddler with severe deep abrasions over
98% of the body .
5. When admitting a client to an acute care facility, an identificationbracelet is
sent up
with the admission form. In the event these do not match, the nurse’sbest action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement issupplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client
The correct answer is C: notify the admissions office andwait to
apply the bracelet
6. The nurse is having difficulty reading the health care provider's writtenorder that
was
written right before the shift change. What action should be taken?
A) Leave the order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification
The correct answer is D: Call the provider for clarification
7. An adult client is found to be unresponsive on morning rounds. Afterchecking
for
, responsiveness and calling for help, the next action that should be takenby the nurse
is
to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway
The correct answer is D: open the client''s airway
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