EXIT HESI -PN Exam A PRACTICE
QUESTION
A 2-day postpartum mom who's breastfeeding asks, "Why do I experience this tingling in my
breasts after the child sucks for a few minutes?" Which records need to the nurse provide?
A.This feeling occurs at some point of feeding with a breast infection.
B.This sensation happens as breast milk movements to the nipple.
C.The toddler does no longer have correct latch-on.
D.The toddler is not positioned successfully. - ANS-B
When the mom's milk is available in, normally 2 to 3 days after delivery, girls often report they
experience a tingling sensation of their nipples (B) when let-down takes place. (A, C, and D)
provide faulty records.
A 40-yr-old workplace worker who's at 36 weeks' gestation presents to the occupational fitness
sanatorium complaining of a pounding headache, blurry vision, and swollen ankles. Which
intervention must the nurse implement first?
A.Check the purchaser's blood strain.
B.Teach her to elevate her feet whilst sitting.
C.Obtain a 24-hour food regimen records to evaluate for the intake of salty meals.
D.Assess the fetal coronary heart rate. - ANS-A
The blood stress (A) ought to be assessed first. Preeclampsia is a multisystem disorder, and
girls older than 35 years and feature continual hypertension are at multiplied hazard. Classic
signs encompass headache, visual modifications, edema, recent speedy weight gain, and
improved blood strain. (B, C, and D) can be performed if the blood strain is everyday.
A 50-year-antique guy arrives on the medical institution with complaints of pain on ejaculation.
Which motion ought to the nurse put in force?
A.Teach the client testicular self-exam (TSE).
B.Assess for the presence of blood inside the urine.
C.Ask about scrotal ache or blood within the semen.
D.Inquire about a history of kidney stones. - ANS-C
Orchitis is an acute testicular irritation as a result of recurrent urinary tract infection, recurrent
sexually transmitted disorder (STD), or an indwelling urethral urinary catheter causing pain on
ejaculation, scrotal ache, blood within the semen, and penile discharge, so the nurse need to
decide the presence of different symptoms (C). Although all guys must exercise TSE, the
patron's signs and symptoms are suggestive of an inflammatory syndrome rather than testicular
most cancers (A). Although hematuria (B) is related to renal ailment or calculi (D), the
purchaser's pain is related to ejaculate, not urine.
,A 77-12 months-antique female client states that she has in no way been so massive across the
waist and that she has common durations of constipation. Colon disorder has been dominated
out with a flexible sigmoidoscopy. Which records must the nurse offer to this client?
A.As girls age, they frequently turn out to be rounder inside the center because they do now not
exercising well.
B.Further evaluation is indicated due to the fact lack of stomach muscle tone and constipation
do no longer arise with getting older.
C.With age, more fatty tissue develops within the abdomen and reduced intestinal motion can
reason constipation.
D.Because there is no proof of a diseased colon, there may be no need to fear about belly
length - ANS-C
With growing older, the belly muscular tissues weaken as fatty tissue is deposited around the
trunk and waist. Slowing peristalsis also impacts the emptying of the colon, ensuing in
constipation (C). (A) isn't the primary motive for the adjustments in body structure. (B) isn't
indicated because lack of muscle tone and constipation are age-related adjustments. (D)
dismisses the purchaser's worries and does no longer help her apprehend the modifications that
she is experiencing.
A toddler is having a generalized tonic-clonic seizure. Which action have to the nurse take?
A.Move gadgets out of the kid's instantaneous place.
B.Quickly slip gentle restraints on the kid's wrists.
C.Insert a padded tongue blade among the teeth.
D.Place within the restoration function before going for assist. - ANS-A
The first priority during a seizure is to provide a secure surroundings, so the nurse need to clear
the vicinity (A) to reduce the risk of trauma. The toddler have to not be confined (B) due to the
fact this can reason extra trauma. Objects ought to now not be located inside the baby's mouth
(C) due to the fact it is able to pose a choking danger. Although (D) should be carried out after
the seizure, the nurse must no longer leave the child during a seizure to get help.
A baby with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of breakfast
meals at a fast food restaurant indicates that the mother knows the dietary guidelines vital for
her child?
A.French toast sticks and orange juice
B.Sausage egg muffin and grape juice
C.Canadian bacon slices and warm chocolate
D.Toasted oat cereal and occasional-fats milk - ANS-D
A toddler receiving a corticosteroid for nephrotic syndrome have to comply with a low-sodium,
low-fat, and coffee-sugar food regimen. Based on those guidelines, the excellent breakfast
preference is (D). (A) is high in fat and sugar. (B and C) are high in fats and sodium.
A purchaser has been on a mechanical ventilator for several days. What ought to the nurse use
to report and document this patron's respirations?
A.The respiratory settings on the ventilator
, B.Only the purchaser's spontaneous respirations
C.The ventilator-assisted respirations minus the purchaser's impartial breaths
D.The ventilator setting for respiratory rate and the patron-initiated respirations - ANS-D
The nurse should depend the patron's respirations, and record both the respiratory fee set by
using the ventilator and the consumer's independent respiratory rate (D). Never depend strictly
on (A). Although the purchaser's spontaneous breaths will be shallow and device-assisted
breaths can be deep, it's far critical to report machine-assisted breaths in addition to the patron's
spontaneous breaths to get an normal respiratory picture of the patron (B and C).
A customer has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days.
The UAP reports to the nurse that the client has had 3 free foul-smelling stools this morning.
Which intervention is maximum crucial for the nurse to put in force?
A.Perform a virtual assessment for fecal impaction.
B.Administer a PRN dose of psyllium (Metamucil).
C.Obtain a stool specimen for culture and sensitivity.
D.Instruct the UAP to attain incontinent pads for the customer. - ANS-C
Long-term use of levofloxacin (Levaquin) can cause foul-smelling diarrhea because of
Clostridium difficile infection or associated colitis, so it is maximum essential to achieve a stool
specimen (C). Impaction is unlikely, so (A) is of much less precedence and won't be important.
(B) is a bulk-forming agent that can be used for constipation or diarrhea. Treatment of the
diarrhea and client comfort (D) are crucial interventions however of less priority than figuring out
the cause of the purchaser's diarrhea.
A purchaser hospitalized for meningitis is demonstrating nuchal pressure. Which symptom is
this patron possibly to be showing?
A.Hyperexcitability of reflexes
B.Hyperextension of the top and lower back
C.Inability to flex the chin to the chest
D.Lateral facial paralysis - ANS-C
Nuchal stress (neck stiffness) is a characteristic of meningeal infection and is elicited with the
aid of attempting to flex the neck and location the chin to the chest (C). Although (A, B, and D)
may additionally arise in meningitis, (A) describes exaggerated spinal nerve reflex responses,
(B) describes opisthotonus, and (D) may be related to cranial nerve pathology of the trigeminal
nerve.
A purchaser is admitted to the intellectual health unit with a main criticism of crying, depressed
temper, and slumbering difficulties. While speakme about the demise of a pal, the consumer
states, "I can not consider this took place." Which statement with the aid of the nurse is
maximum therapeutic?
A."It feels like you are feeling very sad."
B."Tell me extra approximately how you are feeling."
C."How regularly do you have crying spells?"
D."Do you need to talk approximately those emotions?" - ANS-B
, It is maximum therapeutic to invite an open-ended question and encourage the consumer to
discover his or her feelings (B). (A) is a leading response, and the client might not be feeling
sad. (C and D) are close-ended questions that do not facilitate verbal exchange.
A purchaser reviews experiencing dysuria and urinary frequency. Which consumer coaching
should the nurse offer?
A.Save the subsequent urine sample.
B.Restrict oral fluid consumption.
C.Strain all voided urine.
D.Reduce physical interest. - ANS-A
The nurse ought to train the customer to save the next urine pattern (A) for commentary of its
look and for possible urinalysis. The patron is reporting symptoms which can indicate the onset
of a urinary tract infection. Increased fluid consumption must be encouraged, except
contraindicated (B). (C) is best necessary if a calculus (stone) is suspected. (D) isn't indicated
by means of this client's symptoms.
A client tells the nurse that he is affected by insomnia. Which data is most vital for the nurse to
achieve?
A.The customer's normal sound asleep sample
B.Whether the purchaser smokes
C.How a good deal liquid the customer consumes earlier than bedtime
D.The amount of caffeine that the client consumes in the course of the day - ANS-A
The first factor to determine is the patron's standard sleeping sample and how it has changed to
emerge as what the consumer describes as insomnia (A). (B, C, and D) provide extra data after
(A) is ascertained.
A client who's admitted with emphysema is having difficulty breathing. In which function have to
the nurse vicinity the purchaser?
A.High Fowler's function without a pillow behind the pinnacle
B.Semi-Fowler's function with a single pillow in the back of the pinnacle
C.Right aspect-mendacity role with the head of the bed increased 45 levels
D.Sitting upright and ahead with each palms supported on an over the mattress table - ANS-D
Adequate lung enlargement is dependent on deep breaths that allow the respiration muscular
tissues to increase the longitudinal and anterior-posterior length of the thoracic cage. Sitting
upright and leaning ahead with the palms supported on an over the mattress table (D) permits
the thoracic cage to increase in all four guidelines and reduces dyspnea. A high Fowler's
position does now not permit most enlargement of the posterior lobes of the lungs (A). A
semi-Fowler's role restricts growth of the anterior-posterior diameter of the thoracic cage (B).
Positioning a purchaser on the right side with the top of the mattress multiplied (C) does no
longer facilitate lung expansion.
A patron who's on the outpatient surgical unit is making ready for discharge after a myringotomy
with placement of ventilating tubes. Which reaction by using the purchaser shows that further
coaching is necessary?
