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2022 HESI PN V4 EXIT EXAM 110
QUESTION AND ANSWER(S)
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will
drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the
best follow-up action by the nurse? Correct Answer: Review with the client the need to avoid foods that
are rich in milk and cream
A male client with hypertension, who received new antihypertensive prescriptions at his last
visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is
158/106 and he admits that he has not been taking the prescribed medication because 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 which pathophysiological condition? Correct
Answer: Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted
client who has a seizure disorder. The client is supine and the UAP is placing soft pillows
along the side rails. What action should the nurse implement? Correct Answer: Instruct the UAP to
obtain soft blankets to secure to the side rails instead of pillows.
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the
past 12 days. Which assessment finding requires immediate follow-up? Correct Answer: Describes life
without purpose
A 60-year-old female client with a positive family history of ovarian cancer has developed an
abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap)
,smear results are negative. What information should the nurse include in the client's teaching
plan? Correct Answer: Further evaluation involving surgery may be needed
A client who recently underwear a tracheostomy is being prepared for discharge to home.
Which instructions is most important for the nurse to include in the discharge plan? Correct Answer:
Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen
reservoir bag does not deflate completely during inspiration and the client's respiratory rate is
14 breaths / minute. What action should the nurse implement? Correct Answer: Document the
assessment data — Rational: reservoir bag should not deflate
completely during inspiration and the client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which
client alarm should the nurse investigate firs? Correct Answer: Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What
action should the nurse take first? Correct Answer: Check the client for lacerations or fractures
At 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 to avoid
getting a headache. Which action should the nurse take first? Correct Answer: Inform the anesthesia
care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart
sounds. To determine if an S3 heart sound is present, what action should the nurse take first? Correct
Answer: Listen with the bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance through her place
of employment. Which agency should the client be referred to by the employee health nurse
for health insurance needs? Correct Answer: Medicare
A 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? Correct Answer: Toasted wheat
bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint indicated to
the nurse that the client is experiencing a complication? Correct Answer: "I have a headache that gets
worse when I sit up"
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with
incontinence. Which action should the nurse implement? Correct Answer: Obtain a clean catch mid-
stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that
are in keeping with the child's dietary restrictions. Which foods are contraindicated for this
child? Correct Answer: Foods sweetened with aspartame
,Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the
circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client.
Which response should the circulating nurse provide? Correct Answer: Direct the nurse to continue the
surgical hand scrub for a 5 minute duration
Which breakfast selection indicates that the client understands the nurse's instructions about
the dietary management of osteoporosis? Correct Answer: Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less than
the optimal number of registered nurses will be working that shift. In planning assignments,
which client should receive the most care hours by a registered nurse (RN)? Correct Answer: An 82-
year-old client with Alzheimer's disease newly-fractures femur who has a
Foley catheter and soft wrist restrains applied
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the
pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and
pierced the bottom of the child's foot. Which action should the nurse implement first? Correct Answer:
Cleanse the foot with soap and water and apply an antibiotic ointment
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been
applying triple antibiotic ointment for two days, but there has been no improvement." What
instruction should the nurse provide? Correct Answer: Stop using the ointment and encourage
complete drying of the feet and wearing
clean socks.
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 the nurse that
the prescribed dosage is too high for this client? The client experiences Correct Answer: Palpitations
and shortness of breath
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 to the client? Correct
Answer: Obtain a list of medications taken for cardiac history
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select
all that apply) Correct Answer: - Fluid shifts from intravascular to interstitial area due to decreased
serum protein
- Increased hydrostatic pressure in portal circulation increases fluid shifts into
abdomen
- Increased circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the nurse use to
document this sound? (Please listen to the audio first to select the option that applies) Correct Answer:
Murmur — Rationale: A murmur is auscultated as a swishing sound that is associated
with the blood turbulence created by the heart or valvular defect.
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours
, for four days. What assessment is most important for the nurse to complete? Correct Answer:
Auscultate the client's bowel sounds
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently
causes constipation, so it is most important to Auscultate the client's bowel sounds
A female client is admitted with end stage pulmonary disease is alert, oriented, and
complaining of shortness of breath. The client tells the nurse that she wants "no heroic
measures" taken if she stops breathing, and she asks the nurse to document this in her
medical record. What action should the nurse implement? Correct Answer: Ask the client to discuss "do
not resuscitate" with her healthcare provider
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has
developed diarrhea. The client has a new prescription to change the feeding to half strength.
What intervention should the nurse implement? Correct Answer: Add equal amounts of water and
feeding to a feeding bag and infuse at 50ml/hour
A female client reports that her hair is becoming coarse and breaking off, that the outer part
of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question
is best for the nurse to ask? Correct Answer: Have you noticed any changes in your fingernails? —
Rationale: The pattern of
reported manifestations is suggestive of hypothyroidism
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and
malnutrition. The client is drowsy but responding to verbal stimuli and reports recently
spitting up blood. What assessment finding warrants immediate intervention by the nurse? Correct
Answer: Capillary refill of 8 seconds
After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs
the form as a witness. What are the legal implications of the nurse's signature on the client's
surgical consent form? (Select all that apply) Correct Answer: - The client voluntarily grants permission
for the procedure to be done
- The client is competent to sign the consent without impairment of judgment
- The client understands the risks and benefits associated with the procedure
Following surgery, a male client with antisocial personality disorder frequently requests that
a specific nurse be assigned to his care and is belligerent when another nurse is assigned.
What action should the charge nurse implement? Correct Answer: Advise the client that assignments
are not based on clients requests
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical
radiation implant. While providing care, the nurse finds the radiation implant in the bed.
What action should the nurse take? Correct Answer: Place the implant in a lead container using long-
handled forceps
The client with which type of wound is most likely to need immediate intervention by the
nurse? Correct Answer: Laceration — Rationale: 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
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