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NR 340 HESI Week 8 FINAL EXAM-160 Q & A, NR 340 HESI Exit Exam 1
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Name: Class: Date: ID: ATEST 1
HESI Exit Exam 1
Multiple Choice
Identify the letter of the choice that best completes the statement or answers the question.
1. While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth
on the client's legs. What additional assessment provides further data to support this finding?
a. Palpate for the presence of femoral pulses bilaterally.
b. Assess for the presence of a positive Homan's sign.
c. Observe the appearance of the skin on the client's legs.
d. Watch the client's posture and balance during ambulation.
ANS: C
Signs of chronic arterial insufficiency include decreased hair growth in the legs and feet,
absent or decreased pedal pulses, infection in the foot, poor wound healing, thickened nails,
and a shiny appearance of the skin (C). Femoral pulses (A) should still be palpable in the
diabetic with chronic arterial insufficiency. A positive Homan's sign is an indicator of deep
vein thrombosis (B). (D) would probably not be affected significantly by chronic arterial
insufficiency.
2. The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds.
The drug is diluted in 25 ml of D5W to run over 8 hours. How much Streptomycin will the
infant receive?
a. 9 mg.
b. 18 mg.
c. 27 mg.
d. 36 mg.
ANS: C
4 lbs / 2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C).
NOTE, the fact that the drug is diluted in 25 ml of D5W, is not relevant to the calculation
requested.
3. In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse
determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/minute;
urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/dl. Based on these findings,
what intervention should the nurse implement?
a. Continue the magnesium sulfate infusion as prescribed.
b. Decrease the magnesium sulfate infusion by one-half.
c. Stop the magnesium sulfate infusion immediately.
d. Administer calcium gluconate immediately.
ANS: C
The client is exhibiting symptoms of magnesium sulfate toxicity--decreased reflexes (normal is
+2), a low normal respiratory rate (normal is 12 to 20 breaths/min), a less than average
urinary output (30 ml/hour is average), and a low magnesium sulfate level (normal is 4 to
1
,Name: Class: Date: ID: A
8mg/dl). Based on these findings, the nurse should stop the infusion (C). (A) is
contraindicated. (B) would not fully alleviate the magnesium sulfate toxicity symptoms. (D)
(the antagonist for magnesium sulfate) would be indicated if the respiratory rate were less
than 12 breaths/minute.
4. A client is on a mechanical ventilator. Which client response indicates that the neuromuscular
blocker tubocurarine chloride (Tubarine) is effective?
a. The client’s expremities are paralyzed.
b. The peripheral nerve stimulator causes twitching.
c. The client clinches fist upon command.
d. The client’s Glagow Coma Scale score is 14.
ANS: A
This medication causes paralysis (A) following intravenous injection. Peak effects persist for
35 to 60 minutes. (B and C) would not be possible if the medication is effective. The Glasgow
coma scale is used to evaluate the neurological status of the client and does not evaluate the
effectiveness (D) of this medication.
5. An elderly female client comes to the clinic for a regular check-up. The client tells the nurse
that she has increased her daily doses of acetaminophen (Tylenol) for the past month to
control joint pain. Based on this client's comment, what previous lab values should the nurse
compare with today's lab report?
a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today due
to dehydration.
b. Look for an increase in today's LDH compared to the previous one to assess for
possible liver damage.
c. Expect to find an increase in today's APTT as compared to last quarter's due to
bleeding.
d. Determine if there is a decrease in serum potassium due to renal compromise.
ANS: B
Frequent and/or large doses of acetaminophen can cause an increase in liver enzymes,
indicating possible liver damage (B). If the client reported unusual bleeding, or an increase in
aspirin usage, it would be important for the nurse to assess for increased bleeding and monitor
(A and/or C). (D) is not affected by increases in acetaminophen doses.
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,Name: ID: A
6. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory
process, promote comfort, and reduce fever. What intervention is most important for the
nurse to implement?
a. Instruct the parents to hold the aspirin until the child has first had a tepid sponge
bath.
b. Administer the aspirin with at least two ounces of water or juice.
c. Notify the healthcare provider if the child complains of ringing in the ears.
d. Advise the parents to question the child about seeing yellow halos around objects.
ANS: C
Ringing in the ears (tinnitus) (C) is an important sign of aspirin overdosage and should be
reported immediately. Though a tepid sponge bath may lower the child's temperature, the
prescription for aspirin should not be held (A). Aspirin should be taken with at least eight
ounces of water to completely wash the tablet into the stomach and to help prevent GI
discomfort (B). Yellow halos are associated with Digoxin toxicity, not aspirin (D).
7. Which signs or symptoms are characteristic of an adult client diagnosed with Cushing's
syndrome?
a. Husky voice and complaints of hoarseness.
b. Warm, soft, moist, salmon-colored skin.
c. Visible swelling of the neck, with no pain.
d. Central-type obesity, with thin extremities.
ANS: D
The classic picture of Cushing's syndrome in the adult is central-type obesity with thin
extremities (D), along with a "buffalo hump" in the supraclavicular area, heavy trunk, and
thin fragile skin. The symptoms described in (A) are clinical manifestations of
hypothyroidism, and in (B) of hyperthyroidism. (C) may indicate a goiter or a tumor of the
thyroid gland.
8. A charge nurse agrees to cover another nurse’s assignment during a lunch break. Based on the
status report provided by the nurse who is leaving for lunch, which client should be checked
first by the charge nurse? The client
a. admitted yesterday with diabetec ketoacidosis whose blood glucose level is
now 195 mg/dl.
b. with an ileal conduit created two days ago with a scant amount of blood in
the drainage pouch.
c. post-triple coronary bypass four days ago who has serosanguinous drainage
in the chest tube.
d. with a pneumothorax secondary to a gunshot wound with a current pulse
oximeter reading of 90%.
ANS: D
A pulse oximeter reading of 90% indicates an arterial blood gas of less than 80 to 100 and
should be assessed immediately (D). (A) is an expected finding. (B) is not an unusual finding.
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, Name: ID: A
(C) is an expected finding for this client.
9. An outcome for treatment of peripheral vascular disease is, "The client will have decreased
venous congestion." What client behavior would indicate to the nurse that this outcome has
been met?
a. Avoids prolonged sitting or standing.
b. Avoids trauma and irritation to skin.
c. Wears protective shoes.
d. Quits smoking.
ANS: A
Client behaviors indicating that the expected outcome of, "decreased venous congestion" has
been met would include elevating the legs, increasing walking time, and an observable
decrease in edema of the lower extremities (A). (B and C) would be appropriate for outcomes
for, "Attains or maintains tissue integrity." (D) would be an appropriate outcome for,
"Demonstrates an increase in arterial blood supply to extremities."
10. The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid
are removed. Which assessment parameter is most critical for the nurse to monitor following
the procedure?
a. Pedal pulses.
b. Breath sounds.
c. Gag reflex.
d. Vital signs.
ANS: D
Life-threatening complications such as hypovolemia and sepsis can occur following a
paracentesis, and measurement of vital signs (D) will provide assessment data that will help
detect the occurrence of such complications. (A) might be assessed to check for circulation in
the lower extremities, but are not indicated for postparacentesis assessment. Reduction of (B)
may occur as the result of decreased fluid in the peritoneal cavity, but is a desired outcome,
not a complication, of this procedure. (C) is not affected by a paracentesis procedure.
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