366 EXIT HESI Questions and Correct Answers | Latest Update
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Course
HESI
Institution
HESI
A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not
been sleeping well lately and is experiencing labored breathing. List the client's problems in
order of priority for the nurse. (Rank in the priority order from highest to lowest.)
1.
Airway and bre...
Best Grades | Must Pass | Latest Update | Correct Answers | 2024/ 2025
366 EXIT HESI Questions and Correct
Answers | Latest Update
A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not
been sleeping well lately and is experiencing labored breathing. List the client's problems in
order of priority for the nurse. (Rank in the priority order from highest to lowest.)
1.
Airway and breathing.
2.
Pain management.
3.
Definitive therapy.
4.
Sleep and rest.
Correct Answer:
1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy.
Rationale
First-level problems are immediate priorities (airway, breathing, and circulation). In this
scenario, airway and breathing are the first priority, followed by pain management, Maslow's
hierarchy of basic needs for rest and sleep, and then definitive drug therapies.
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Which biological practices are federally regulated for healthcare workers? (Select all that
apply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
6. As Low as Reasonably Allowable standard (ALARA).
3. Blood-borne pathogen standard.
5. Resource Conservation and Recovery Act (RCRA)
Basic standards for healthcare workers, as delineated by Occupational Safety and Health
Administration (OSHA), include standard precautions, droplet precautions using N-95
respiratory particulate masks when caring for a client who is positive for tuberculosis, and
required annual updates for healthcare workers about blood-borne pathogen transmission,
methods of minimizing exposure, and employee rights. Other options [BPEL and ALARA ] are
not federally regulated.
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A client with severe depression tells the nurse, "I do not know why you bother with me or give
me pills. I am never going to get well." What is the most therapeutic response?
1. "You need to stop thinking negative thoughts. They get in the way of your recovery."
2. "You are no bother to me or to the staff. We want you to get well and not feel sad
anymore."
3. "I have known many clients with depression who have felt better after several weeks of
treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It should go away as you
recover."
3. "I have known many clients with depression who have felt better after
several weeks of treatment."
Stating the observation that others have recovered can give a client hope. Telling a person to
stop negtive thinking is ineffective because the client must be taught cognitive strategies to
stop negative thinking. Stating the person is "no bother" is arguing with the client's beliefs and
attempting to tell him how to feel, both of which are not therapeutic responses. Bring up
pessimistic feelings interprets the client's feelings and does not provide the same degree of
hope.
The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to
inadequate primary defenses as evidenced by surgical incision and IV access." What nursing
intervention should the nurse implement?
1. Limit visitors to immediate family to decrease exposure to infection.
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, Best Grades | Must Pass | Latest Update | Correct Answers | 2024/ 2025
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 requiring close contact.
3. Assess and document skin condition around the incision and IV site at
each shift.
Early identification of infection leads to prompt treatment and decreased nosocomial
transmission to others, so the condition of any invasive lines or breaks in the skin should be
assessed and documented during each shift.
A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J
pouch). As part of preoperative teaching, what information should the nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
4. Stool is eventually expelled through the rectum.
4. Stool is eventually expelled through the rectum.
An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created ileoanal
reservoir in the anal canal that preserves the rectal sphincter muscle, so that passage of stool
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