EXIT HESI - Comprehensive PN Exam A
Practice Questions
A 2-day postpartum mom who's breastfeeding asks, "Why do I experience this tingling in my
breasts after the toddler sucks for a few minutes?" Which records should the nurse offer?
A.This feeling occurs at some point of feeding with a breast contamination.
B.This sensation occurs as breast milk movements to the nipple.
C.The toddler does no longer have suitable latch-on.
D.The infant isn't always located successfully. - ANS-B
When the mother's milk comes in, typically 2 to 3 days after delivery, women regularly report
they experience a tingling sensation of their nipples (B) whilst allow-down occurs. (A, C, and D)
offer misguided data.
A 40-12 months-antique office employee who's at 36 weeks' gestation presents to the
occupational fitness health facility complaining of a pounding headache, blurry imaginative and
prescient, and swollen ankles. Which intervention must the nurse implement first? - ANS-Check
the purchaser's blood pressure.
A 50-year-old guy arrives at the hospital with lawsuits of pain on ejaculation. Which movement
have to the nurse enforce? - ANS-Ask about scrotal pain or blood in the semen.
A 77-yr-old woman customer states that she has never been so massive across the waist and
that she has common durations of constipation. Colon ailment has been ruled out with a bendy
sigmoidoscopy. Which information ought to the nurse provide to this customer? - ANS-With age,
extra fatty tissue develops in the stomach and reduced intestinal motion can motive
constipation.
A toddler is having a generalized tonic-clonic seizure. Which movement must the nurse take?
A.Move gadgets out of the child's immediate location.
B.Quickly slip tender restraints on the child's wrists.
C.Insert a padded tongue blade among the tooth.
D.Place in the recuperation function earlier than going for assist. - ANS-A
The first priority during a seizure is to offer a secure surroundings, so the nurse need to clean
the area (A) to reduce the chance of trauma. The toddler need to not be confined (B) due to the
fact this can cause greater trauma. Objects must not be positioned within the child's mouth (C)
because it can pose a choking chance. Although (D) have to be implemented after the seizure,
the nurse have to now not go away the kid in the course of a seizure to get help.
A baby with nephrotic syndrome is receiving prednisone (Deltasone). Which desire of breakfast
meals at a fast food eating place suggests that the mother understands the nutritional
suggestions important for her child? - ANS-Toasted oat cereal and low-fat milk
,A patron has been on a mechanical ventilator for several days. What need to the nurse use to
report and document this client's respirations? - ANS-The ventilator putting for respiration
charge and the purchaser-initiated respirations
A consumer has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days.
The UAP reports to the nurse that the client has had three unfastened foul-smelling stools this
morning. Which intervention is maximum important for the nurse to put into effect? - ANS-Obtain
a stool specimen for subculture and sensitivity.
A consumer hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is that
this purchaser in all likelihood to be showing?
A.Hyperexcitability of reflexes
B.Hyperextension of the pinnacle and again
C.Inability to flex the chin to the chest
D.Lateral facial paralysis - ANS-C
Nuchal tension (neck stiffness) is a feature of meningeal infection and is elicited by way of trying
to flex the neck and area the chin to the chest (C). Although (A, B, and D) can also arise in
meningitis, (A) describes exaggerated spinal nerve reflex responses, (B) describes
opisthotonus, and (D) can be related to cranial nerve pathology of the trigeminal nerve.
A patron is admitted to the mental fitness unit with a first-rate complaint of crying, depressed
temper, and sound asleep problems. While speaking approximately the dying of a chum, the
customer states, "I can't consider this took place." Which assertion by means of the nurse is
most healing? - ANS-"Tell me greater approximately how you feel."
A consumer reviews experiencing dysuria and urinary frequency. Which purchaser coaching
ought to the nurse provide? - ANS-Save the following urine sample.
A client tells the nurse that he is suffering from insomnia. Which facts is maximum vital for the
nurse to reap? - ANS-The customer's typical napping pattern
A consumer who's admitted with emphysema is having issue respiratory. In which position need
to the nurse location the client? - ANS-Sitting upright and forward with both palms supported on
an over the mattress table
A patron who is at the outpatient surgical unit is getting ready for discharge after a myringotomy
with placement of ventilating tubes. Which response via the consumer indicates that in addition
teaching is vital?
A."I will keep away from coughing, sneezing, and forceful nostril blowing."
B."Swimming can start at the tenth postoperative day."
C."Any mild pain can be controlled with acetaminophen."
D."Drainage from my ears is predicted after the surgery." - ANS-B
The motive of the ventilating tubes inside the tympanic membrane is to equalize strain and drain
fluid collection from the center ear. The tube's patency lets in air and water to go into the center
ear, so the patron have to be reeducated if the client swims (B) or allows water to enter the
outside ear. (A, C, and D) mirror accurate responses.
A patron with acquired immunodeficiency syndrome (AIDS) is hospitalized after a latest
discharge. Which nursing intervention is maximum vital in lowering the patron's pressure
, associated with repeated hospitalization? - ANS-Encourage as plenty independence in choice
making as possible.
A consumer with acute renal failure (ARF) starts to void 4 L/day 2 weeks after remedy is
initiated. Which trouble is vital for the nurse to reveal the client for at this time? -
ANS-Hypotension
A purchaser with continual renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide
(HCTZ) PO and forty mg of furosemide (Lasix) PO day by day. Today, at a recurring hospital go
to, the customer's serum potassium stage is 4 mEq/L. What is the maximum possibly purpose of
this customer's potassium stage? - ANS-The purchaser's renal feature has affected his
potassium level.
A customer with glomerulonephritis is scheduled for a creatinine clearance check to decide the
want for dialysis. Which records should the nurse provide the customer previous to the check?
A.Failure to collect all urine specimens in the course of the length of the study will invalidate the
take a look at.
B.Blood is accrued to measure the quantity of creatinine and determine the glomerular filtration
price (GFR).
C.Dialysis is began whilst the GFR is lower than five mL/min.
D.Discard the primary voiding, and report the time and amount of urine of every voiding for 24
hours. - ANS-A
Glomerulonephritis damages the renal glomeruli and influences the kidney's capacity to clean
serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen check, so all
urine need to be amassed in the course of the duration of the study or the outcomes are
misguided (A). As renal characteristic decreases, the creatinine level will lower in the urine (B).
Dialysis is usually began whilst the GFR is 12 mL/min (C). There isn't any want to document the
frequency and amount of each voiding (D) for the duration of the time span of urine series.
A patron with hemiparesis needs help shifting from the bed to the wheelchair. The nurse assists
the client to a sitting function on the aspect of the mattress. Which movement should the nurse
enforce next? - ANS-Allow the customer to sit at the aspect of the mattress for a couple of
minutes before transferring.
A patron with hemiplegia who is on mattress relaxation is turned to the supine role, and the
nurse determines that the customer's hips are externally turned around. Which intervention is
maximum critical for the nurse to enforce?
A.Request a prescription for a bed board to offer accelerated again aid.
B.Reposition the client in order that both feet are supported by means of the mattress board.
C.Move the trapeze bar to allow the consumer to tug with the upper extremities.
D.Place trochanter rolls on the lateral aspects of the patron's thighs. - ANS-D
Trochanter rolls (D) have to be positioned at the lateral factors of the thighs to prevent outside
rotation of the hips when the purchaser is in a supine function. Although (A, B, and C) are
supportive gadget used to preserve proper positioning of the client who is immobile, it's miles
maximum vital to maintain the decrease extremities in the aligned anatomical function. A
mattress board (A) offers extended again help, specifically with a tender mattress. The
footboard (B) continues the ft in dorsiflexion and prevents foot drop. The trapeze bar (C) permits
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