Exam (elaborations)
HESI EXAM 2
Exam of 31 pages for the course AH1 NCLEX at AH1 NCLEX (HESI EXAM 2)
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HESI EXAM 21. A teenager presents to the emergency department with palpitations after vaping at a party.
The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing
which acid base imbalance?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
Metabolic alkalosis - ANS-b. Respiratory alkalosis
1. Following a cardiac catheterization and placement of a stent in the right coronary artery, the
nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects up
from the medication, which assessment is most important for the nurse to include in the client's
plan of care?
a. Observe color of urine
b. Measure body temperature
c. Assess skin turgor
d. Check for pedal edema - ANS-a. Observe color of urine
1. In assessing a client with type one diabetes mellitus, the nurse notes that the client's
respirations have changed from 16 breaths/minute with a normal depth to 32 breaths/minute
and deep, and the client has become lethargic. Which assessment data should the nurse obtain
next?
a. Temperature
b. Breath sounds
c. Blood glucose
d. White blood cell count - ANS-c. Blood glucose
1. Which laboratory finding for an adult client is most critical for the nurse to report to the health
care provider? (CHART) - ANS-Serum glucose
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries
and saying from a fall. His parents are very concerned that the child has regressed in his
toileting behaviors. Which information should the nurse provide to the parents?
a. A retraining program will need to be initiated when the child returns home
b. Diaper will be provided since hospitalization is stressful to preschoolers
c. A potty chair should be brought home so he can maintain his toileting skills
d. Children usually resume their toileting behaviors when they leave the hospital - ANS-d.
Children usually resume their toileting behaviors when they leave the hospital
,A 7 year old is admitted to the hospital with persistent vomiting and a nasogastric tube attached
to low intermittent suction is applied. Which finding is most important for the nurse to report to
the health care provider?
a. Shift intake of 640 milliliters IV fluids plus 30 milliliters PO ice chips
b. Serum ph of 7.45
c. Gastric output of 100 milliliters in the last eight hours
d. Serum potassium of 3.0 milligrams per deciliter - ANS-d. Serum potassium of 3.0 milligrams
per deciliter
A child newly diagnosed with sickle cell anemia is being discharged from the hospital. Which
information is most important for the nurse to provide to the parents prior to discharge?
a. Instructions about how much fluid the child should drink daily
b. Signs of addiction to opioid pain medications
c. Information about non-pharmaceutical pain relief measures
d. Referral for social services for the child and family - ANS-
A client asked the nurse for information about how to reduce risk factors for benign prostatic
hyperplasia. Which information should the nurse provide?
a. Consume a high protein diet
b. Increase physical activity
c. Take vitamin supplements
d. Obtain a prostate specific antigen blood level test - ANS-b. Increase physical activity
A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of
hyperemesis gravidarum. The which action is most important for the nurse to implement?
a. Obtain the client's 24 hour dietary recall
b. Document mucosal membrane status
c. Schedule a consult with a nutritionist
d. Initiate prescribed intravenous fluids - ANS-d. Initiate prescribed intravenous fluids
A client diagnosed with calcium kidney stones has a history of gout. A new prescription for
aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse
bring to the healthcare providers attention?
a. Enapril
b. Allopurinol
c. Fureosemide
d. Aspirin low dose - ANS-b. Allopurinol
A client in the emergency center demonstrates rapid speech, flight of ideas, and reports
sleeping only three hours during the last 48 hours. Based on these findings it is most important
for the nurse to review the laboratory value for which medication?
a. Lorazepam
b. Fluoxetine
c. Divalproex
,d. Olanzapine - ANS-c. Divalproex
A client in the third trimester of pregnancy reports that she feels some lumpy places in her
breasts and that her nipples sometimes leak yellowish fluid. She has an appointment with her
health care provider in two weeks. Which action should the nurse take?
a. Tell the client to begin nipple stimulation to prepare for breastfeeding
b. Reschedule the clients prenatal appointment for the following day
c. Explain that this is normal secretion and can be assessed at the next visit
d. Recommend that the client start wearing a supportive bra - ANS-c. Explain that this is normal
secretion and can be assessed at the next visit
A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse
to report to the health care provider?
a. Volume of each voiding is more than 300 milliliters
b. Serum potassium level is elevated
c. Relief of flank pain that is radiated into the groin
d. Hematuria that is beginning to turn pink - ANS-b. Serum potassium level is elevated
A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most
important in the plan of care?
a. Risk for ineffective self-health management related to deficient knowledge
b. Ineffective coping related to personal vulnerability
c. Risk for injury related to vertigo
d. Anxiety related to disruption of lifestyle - ANS-c. Risk for injury related to vertigo
A client is found the bathroom when left unattended by the unlicensed assistive personnel.
Which information should the nurse include in the client's health record?
a. The UAP left the client to assist another client
b. The last time the client was assisted to the bathroom
c. The unit was understaffed when the client fell
d. The client fell sustaining a fractured to the left hip - ANS-d. The client fell sustaining a
fractured to the left hip
A client is receiving enoxaparin 30 milligrams subcutaneously twice a day. In assessing for
adverse effects of the medication, which serum laboratory value is most important for the nurse
to monitor?
a. Glucose
b. Calcium
c. Platelet count
d. White blood cell count - ANS-c. Platelet count
A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin
and heparin are infusing. The client is sedated but responds to verbal instructions. After
, changing positions, the client complains of pain at the right groin insertion site. Which action
should the nurse implement?
a. Check femoral site for hematoma formation
b. Stimulate the client to take deep breaths
c. Evaluate the integrity of the IV insertion site
d. Assess distal lower extremity capillary refill - ANS-b. Stimulate the client to take deep breaths
A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for
pulmonary embolism. Which information in the client's history requires follow up by the nurse?
a. CT scan that was performed six months earlier
b. Metal hip prosthesis was placed twenty years ago
c. Report of client sobriety for the past five years
d. Takes metformin for type 2 diabetes mellitus - ANS-d. Takes metformin for type 2 diabetes
mellitus
A client presents the believer in delivery unit with a report of leaking fluid that is greenish brown
vaginal discharge. Which action should the nurse take first?
a. Start an intravenous infusion
b. Administer oxygen via face mask
c. Performing vaginal exam
d. Begin continuous fetal monitoring - ANS-d. Begin continuous fetal monitoring
A client presents to the emergency department with muscle aches, headache, fever, and
describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19
testing. Which action is most important for the nurse to take?
a. Place a nasal swab specimen for COVID-19 directly into a biohazard bag
b. Move the client to a private room, keep the door closed, and initiate droplet precautions
c. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the
virus
d. Explain to the client to inform others that they may have been potentially exposed in the last
14 days - ANS-a. Place a nasal swab specimen for COVID-19 directly into a biohazard bag
A client presses the call bell and requests pain medication for severe headache. To assess the
quality of the clients pain, which approach should the nurse use?
a. Ask the client to describe the pain
b. Observe body language and movement
c. Identify effective pain relief measures
d. Provided numeric pain scale - ANS-a. Ask the client to describe the pain
A client taking clopidogrel reports the onset of diarrhea. Which nursing actions should the nurse
implement first?
a. Observe the appearance of the stool
b. Assess the elasticity of the client skin
c. Review the client's laboratory values
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