366 EXIT HESI EXAM TEST WITH VERIFIED ANSWERS 100% PASS
1. A newly admitted client com- Correct Answer:
plains of pain rating a 7 on a 1.Airway and breathing. 2.Pain manage-
scale of 0 to 10. The client has not ment. 3.Sleep and rest. 4.Definitive ther-
been sleeping well lately and is apy.
experiencing labored breathing. Rationale
List the client's problems in order
of priority for the nurse. (Rank in First-level problems are immediate prior-
the priority order from highest to ities (airway, breathing, and circulation).
lowest.) In this scenario, airway and breathing
1. are the first priority, followed by pain
Airway and breathing. management, Maslow's hierarchy of ba-
2. sic needs for rest and sleep, and then
Pain management. definitive drug therapies.
3.
Definitive therapy.
4.
Sleep and rest.
2. Which biological practices are 3. Blood-borne pathogen standard.
federally regulated for healthcare 5. Resource Conservation and Recov-
workers? (Select all that apply.) ery Act (RCRA)
Select all that apply
Basic standards for healthcare workers,
1. Standard precautions. as delineated by Occupational Safety
2. N-95 tuberculosis standard. and Health Administration (OSHA), in-
3. Blood-borne pathogen stan- clude standard precautions, droplet pre-
dard. cautions using N-95 respiratory particu-
4. Biological product exposure late masks when caring for a client who
limit (BPEL). is positive for tuberculosis, and required
5. Resource Conservation and annual updates for healthcare work-
Recovery Act (RCRA). ers about blood-borne pathogen trans-
6. As Low as Reasonably Allow- mission, methods of minimizing expo-
able standard (ALARA). sure, and employee rights. Other options
[BPEL and ALARA ] are not federally
regulated.
3. A client with severe depression 3. "I have known many clients with de-
tells the nurse, "I do not know pression who have felt better after sev-
why you bother with me or give eral weeks of treatment."
, 366 EXIT HESI EXAM TEST WITH VERIFIED ANSWERS 100% PASS
me pills. I am never going to get
well." What is the most therapeu- Stating the observation that others have
tic response? recovered can give a client hope. Telling
1. "You need to stop thinking a person to stop negtive thinking is in-
negative thoughts. They get in effective because the client must be
the way of your recovery." taught cognitive strategies to stop neg-
2. "You are no bother to me or to ative thinking. Stating the person is "no
the staff. We want you to get well bother" is arguing with the client's be-
and not feel sad anymore." liefs and attempting to tell him how to
3. "I have known many clients feel, both of which are not therapeutic
with depression who have felt responses. Bring up pessimistic feelings
better after several weeks of interprets the client's feelings and does
treatment." not provide the same degree of hope.
4. "You are feeling very pes-
simistic, but that is part of your
illness. It should go away as you
recover."
4. The nurse is caring for a client 3. Assess and document skin condition
with a nursing problem of, "In- around the incision and IV site at each
fection, risk for, related to inad- shift.
equate primary defenses as evi-
denced by surgical incision and Early identification of infection leads to
IV access." What nursing inter- prompt treatment and decreased noso-
vention should the nurse imple- comial transmission to others, so the
ment? condition of any invasive lines or breaks
1. Limit visitors to immediate in the skin should be assessed and doc-
family to decrease exposure to umented during each shift.
infection.
2. Maintain "clean" technique in
the change of wound dressing
and IV site.
3. Assess and document skin
condition around the incision
and IV site at each shift.
4. Require the use of a face mask
by staff when providing care re-
quiring close contact.
, 366 EXIT HESI EXAM TEST WITH VERIFIED ANSWERS 100% PASS
5. A client with ulcerative colitis is 4. Stool is eventually expelled through
scheduled for surgical creation the rectum.
of an ileoanal reservoir (J pouch).
As part of preoperative teach-
ing, what information should the An ileal pouch-anal anastomosis (also
nurse provide? known as the J pouch) is a surgical-
1. The transverse loop ostomy is ly created ileoanal reservoir in the anal
permanent. canal that preserves the rectal sphincter
2. Easily removable appliances muscle, so that passage of stool through
allow independence in self-care. the rectum is the eventual result. To pro-
3. Daily irrigation is started after mote healing of the anastomosed parts
the J pouch heals. of the colon, a temporary loop ostomy is
4. Stool is eventually expelled created, not a permanent one. Although
through the rectum. appliances that are easy to use are ad-
vantageous, the ostomy is reversed after
healing takes place. Stool drains into the
reservoir, so daily irrigation is not usually
indicated.
6. The nurse inflates the cuff on 4. Inject air until no air is auscultated
a tracheostomy tube to minimal over the larynx during a deep breath.
occlusion pressure for a client
who is breathing spontaneously. To achieve minimal pressure (minimal
Which action should the nurse occlusion volume technique) against the
follow? tracheal wall, inject air into the tra-
1. Check the pilot balloon to en- cheostomy tube cuff while auscultating
sure that it is firm. with a stethoscope placed over the lar-
2. Verify the healthcare provider's ynx (over the cuff) during inhalation. At
prescription for the required cuff the point when sounds of air movement
pressure. cease, inflation is stopped, indicating
3. Use a manometer to maintain that the cuff is sealed against the tra-
cuff pressure between 25 and 30 cheal wall.
mmHg.
4. Inject air until no air is aus-
cultated over the larynx during a
deep breath.
7. A 60-year-old homeless man who 1. Refer for further diagnostic evaluation.
complains of a cough, late-af-
, ternoon fever, and night sweats The PPD skin test results is indica-
has a 10 mm induration after re- tive of exposure or latent Mycobacteri-
ceiving a purified protein deriva- um tuberculosis infection (LTBI), which
tive (PPD) skin test. Which action this client is in a high-risk category for
should the nurse implement? exposure in a homeless environment.
1. Refer for further diagnostic Although productive prolonged cough,
evaluation. fever, and night sweats are common ear-
2. Determine exposure of others ly symptoms, persons suspected of LTBI
to the tuberculosis. should not begin treatment until active
3. Begin anti-tubercular drug TB disease has been excluded. Further
therapy. diagnostic evaluation should be imple-
4. Quarantine or isolate to control mented. A dormant form that neither
communicability. causes disease nor is communicable.
8. Which contextual factors are 1. Economics.
considered external environmen- 3. Technology.
tal influences in the frame- 6. Legislation/regulation.
work for occupational health pro-
grams and services? (Select all Economics affects the health of the
that apply.) company and its workforce productivi-
Select all that apply ty, in termsof profitability, growth, and
1. Economics. expansion. Technology adds to an in-
2. Workforce. dustry's capacity to develop and imple-
3. Technology. ment new or improved work processes.
4. Interventions. Legislation/regulation in the workplace,
5. Socio-economic status. such as the blood-borne pathogen stan-
6. Legislation/regulation. dard, affects the workforce in terms of
requirements, administration, and con-
trol strategies. Occupational safety pro-
grams are built around the workforce to
strive for maximum internal productivity.
Interventions are internal environmental
influences of an occupational health and
safety program. Socio-economic status
is a demographic variable commonly
used in epidemiology.
9. The nurse is analyzing the wave- 4. QRS interval of 0.14 second.
forms of a client's electrocardio-
