2022 HESI RN EXIT EXAM V3
1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suct...
2022 hesi rn exit exam v3 1 a male client with stomach cancer returns to the unit following a total gastrectomy he has a nasogastric tube to suction and is receiving lactated ringer’s solution at 7
1. A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated
Ringer’s solution at 75 mL/hour IV. One hour after admission to the unit, the
nurse notes 300 mL of blood in the suction canister, the client’s heart rate is 155
beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting
the finding to the surgeon. Which action should the nurse implement first?
a. Measure and document the client’s urinary output.
b. Request the client’s reserved unit if packed red blood cells.
c. Prepare the placement of a central venous
catheter.
d. d. Increase the infusion rate of Lactated
Ringer’s solution.
2. an adult male who fell 20 feet from the roof of this home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). the nurse notes
that the suction control chamber is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75
ml of bright red blood is measured in the collection chamber. Which intervention
should the nurse implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as autotransfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in water seal.
3. A client who received hemodialysis yesterday is experiencing a blood pressure
of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36
breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal
edema, and an oxygen saturation on room air of 89%. Which action should the
nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client’s fluid.
c. c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.
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