PN HESI Exit Exam Flashcards - flashcards
Action for a 2-month old infant with a heart rate of 120 beats/min - ANSWER-Give the medication and
document the heart rate
Action for a catheter slipping into the vagina during insertion - ANSWER-Keep the catheter in the vagina
and insert a new catheter through the urethral meatus
Action for a client who has not voided after catheter removal - ANSWER-Obtain an order for
intermittent urinary catheterization
Action for a client who increased protein and calorie intake with hyperthyroidism - ANSWER-Encourage
the client to continue dietary changes
Action for a client with apical pulse rate of 98 bpm followed by 54 bpm - ANSWER-Determine the level
of consciousness
Action for a client with chest tubes and water-sealed chambers - ANSWER-Maintain system integrity and
promote lung re-expansion
Action for a client with increasing fatigue during radiation treatments - ANSWER-Reinforce the need for
extra rest and sleep
Action for a client with numbness and tingling in extremities - ANSWER-Review the client's serum
electrolyte levels
Action for a client with serum potassium of 3.0 mEq/L - ANSWER-Increase intake of dried peaches and
apricots
Action for an elderly client with nonproductive cough and increased vital signs - ANSWER-Report the
findings to the charge nurse
Action for finding a male resident in bed with a female resident in a long-term care facility - ANSWER-
Close the door and report the finding
Action for nipple pain during breastfeeding - ANSWER-Ensure all areolar tissue is in the infant's mouth
Action for observing urine appearance in a client with urinary catheter - ANSWER-Observe the
appearance of urine in the drainage tubing
Additional information to assess for a client with difficulty swallowing solid food - ANSWER-History of
alcohol and tobacco use
Assessment for a client on isotretinoin treatment for severe acne - ANSWER-Ask about occurrence and
frequency of nosebleeds
Assignments for an extended care rehabilitation facility - ANSWER-Toileting assistance, daily skin care,
morning care
Blood pH value for a client with respiratory acidosis - ANSWER-7.29
Client requiring immediate intervention based on trembling and glucose level - ANSWER-Client with
glucose level of 50
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