HESI PN COMPREHENSIVE EXIT EXAM B
HESI PN COMPREHENSIVE EXIT EXAM B
[Document subtitle]
HESI Comprehensive PN EXIT Exam B
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediat...
hesi pn comprehensive exit exam b document subtitle hesi comprehensive pn exit exam b the nurse is caring for a client with a cerebrovascular accident cva wh
Written for
HESI PN COMPREHENSIVE
All documents for this subject (138)
Seller
Follow
user123qw
Reviews received
Content preview
HESI PN COMPREHENSIVE
EXIT EXAM B
[Document subtitle]
,HESI Comprehensive PN EXIT Exam B
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube
feedings. Which task performed by the UAP requires immediate intervention by the nurse?
A. Suctions oral secretions from mouth
B. Positions head of bed flat when changing sheets
C. Takes temperature using the axillary method
D. Keeps head of bed elevated at 30 degrees
B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for
aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).
When caring for a postsurgical client who has undergone multiple blood transfusions, which serum
laboratory finding is of most concern to the nurse?
A. Sodium level, 137 mEq/L
B. Potassium level, 5.5 mEq/L
C. Blood urea nitrogen (BUN) level, 18 mg/dL
D. Calcium level, 10 mEq/L
B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0
mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine
A
Rationale:
,The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is not
recommended until adolescence (B). Varicella immunization begins at 12 months (C). Meningococcal
vaccine is administered beginning at 2 years (D).
The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive
personnel (UAP)?
A. Assess the need to change a central line dressing.
B. Obtain a fingerstick blood glucose level.
C. Answer a family member's questions about the client's plan of care.
D. Teach the client side effects to report related to the current medication regimen.
B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to
perform (B). (A, C, and D) are skills that cannot be delegated to UAP.
The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen
activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select all that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C. Assess the client for signs of bleeding during and after the infusion.
D. Start t-PA within 6 hours after the onset of stroke symptoms.
E. Initiate multidisciplinary consult for potential rehabilitation.
B,C,E
Rationale:
Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This includes close
monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic
impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA
because it increases the risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is
concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent
for a stroke (D).
When caring for a client in labor, which finding is most important to report to the primary health care
provider?
, A. Maternal heart rate, 90 beats/min.
B. Fetal heart rate, 100 beats/min
C. Maternal blood pressure, 140/86 mm Hg
D. Maternal temperature, 100.0° F
B
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average FHR at term
is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C, and D) are normal
findings for a woman in labor.
The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink
frothy sputum. Which action should the nurse take first?
A. Draw arterial blood gases.
B. Notify the primary health care provider.
C. Position in a high Fowler's position with the legs down.
D. Obtain a chest X-ray.
C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet will decrease further venous return
to the left ventricle (C). The other actions should be performed after the change in position (A, B, and D).
A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a shuffling
gait, and tremors. Which action by the nurse is most important?A.Administer a dose of benztropine
mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations.
A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are
extrapyramidal side effects associated with Thorazine. It is most important for the nurse to administer
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller user123qw. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $13.04. You're not tied to anything after your purchase.
