FINAL HESI EXIT 180 QUESTIONS WITH 100% CORRECT ANSWERS LATEST ACTUAL EXAM Final HESI EXIT The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take? 1. Leave the cuff inf lated and suction through the tracheostomy. 2. Deflate the cuff and suction through the tracheostomy tube. 3. Inflate the cuff pressure to 40 mm Hg before suctioning. 4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. - correct answer 1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration; cuff position and pressure should be assessed frequently; swallowing and breathing will cause tracheostomy tube movement 2) Implementation: outcome not de sired; accumulated oral secretions above the cuff will drain into the bronchi; increased risk of infection 3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm H2O); risk of trauma to trachea with higher pressures 4) Implementation: outcome not desired; increases the risk of trauma to lower airways A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate? 1. Assess pu pil size and reactivity. 2. Assess oxygen saturation levels. 3. Palpate dorsalis pedis pulses. Final HESI EXIT 4. Ask the client if he knows today's date. - correct answer 1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose 2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and possible respiratory arrest 3) Assessment: outcome not priority; most important to assess airway and breathing 4) Assessment: outcome not p riority but may be appropriate; drowsiness and euphoria may be seen; not priority The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask? 1. "Have you tried other methods to stop smoking?" 2. "How long have you been smoking?" 3. "Have you ever had chest pain?" 4. "Do you have a partial dental bridge?" - correct answer 1) Assessment: outcome not priority but may be appropriate; can be aske d as part of assessment 2) Assessment: outcome not priority but may be appropriate; should be assessed for further teaching 3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases heart rate and myocardial oxygen cons umption; increased risk of angina and myocardial infarction Final HESI EXIT 4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and gums; may stain dental work The nurse cares for the client with a client controlled analgesia (PCA) pump . The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take? 1. Assess the patency of the PCA IV tubing. 2. Determine the client 's understanding of the PCA pump function. 3. Obtain an order to begin a PCA infusion of fentanyl. 4. Ask the client to describe the pain. - correct answer 1) Assessment: outcome not priority but may be appropriate; if tubing is obstructed, alarm is acti vated 2) Assessment: outcome may be appropriate but not priority; more important to determine pain level, description of the pain, region and radiation of the pain, and relieving factors 3) Implementation: outcome not desired; more important to assess se verity of pain and pain relief first 4) CORRECT - Assessment: outcome priority; must validate that client is in pain before implementation A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's bloo d pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate? 1. Place the client flat on her back.
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