HESI RN EXIT EXAM V1-V7 done
HESI RN EXIT EXAM V1-V7
1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?
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hesi rn exit exam v1 v7 1 following discharge teaching
a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products
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HESI RN EXIT EXAM V1-V7
1. Following discharge teaching, a male client with duodenal ulcer tells the
nurse the he will drink plenty of dairy products, such as milk, to help
coat and protect his ulcer. What is the best follow-up action by the
nurse?
Review with the client the need to avoid foods that are rich in milk
and cream
2. A male client with hypertension, who received new antihypertensive
prescriptions at his last visit returns to the clinic two weeks later to
evaluate his blood pressure (BP). His BP is 158/106 and he admits that
he has not been taking the prescribed medication because the drugs
make him “feel bad”. In explaining the need for hypertension control,
the nurse should stress that an elevated BP places the client at risk for
which pathophysiological condition?
Stroke secondary to hemorrhage
3. The nurse observes an unlicensed assistive personnel (UAP)
positioning a newly admitted client who has a seizure disorder. The
client is supine and the UAP is placing soft pillows along the side
rails. What action should the nurse implement?
Instruct the UAP to obtain soft blankets to secure to the
side rails instead of pillows.
4. An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for the past 12 days. Which assessment finding
requires immediate follow-up?
Describes life without purpose
5. A 60-year-old female client with a positive family history of ovarian
cancer has developed an abdominal mass and is being evaluated for
possible ovarian cancer. Her Papanicolau (Pap) smear results are
negative. What information should the nurse include in the client’s
teaching plan?
Further evaluation involving surgery may be needed
6. A client who recently underwear a tracheostomy is being prepared for
discharge to home. Which instructions is most important for the nurse
to include in the discharge plan?
Teach tracheal suctioning techniques
7. In assessing an adult client with a partial rebreather mask, the nurse
notes that the oxygen reservoir bag does not deflate completely
during inspiration and the client’s respiratory rate is 14 breaths /
minute. What action should the nurse implement?
Document the assessment data
Rational: reservoir bag should not deflate completely during
inspiration and the client’s respiratory rate is within normal
limits.
,8. During shift report, the central electrocardiogram (EKG)
monitoring system alarms. Which client alarm should the nurse
investigate firs?
Respiratory apnea of 30 seconds
9. During a home visit, the nurse observed an elderly client with diabetes
slip and fall. What action should the nurse take first?
Check the client for lacerations or fractures
10. At 0600 while admitting a woman for a schedule repeat cesarean
section (C-Section), the client tells the nurse that she drank a cup a
coffee at 0400 because she wanted to avoid getting a headache.
Which action should the nurse take first?
Inform the anesthesia care provider
11. After placing a stethoscope as seen in the picture, the nurse
auscultates S1 and S2 heart sounds. To determine if an S3 heart
sound is present, what action should the nurse take first?
Listen with the bell at the same location
12. A 66-year-old woman is retiring and will no longer have a health
insurance through her place of employment. Which agency should
the client be referred to by the employee health nurse for health
insurance needs?
Medicare
13. A client who is taking an oral dose of a tetracycline complains of
gastrointestinal upset. What snack should the nurse instruct the
client to take with the tetracycline?
Toasted wheat bread and jelly
14. Following a lumbar puncture, a client voices several
complaints. What complaint indicated to the nurse that the
client is experiencing a complication?
“I have a headache that gets worse when I sit up”
“I am having pain in my lower back when I move my legs”
“My throat hurts when I swallow”
“I feel sick to my stomach and am going to throw up”
15. An elderly client seems confused and reports the onset of
nausea, dysuria, and urgency with incontinence. Which action
should the nurse implement?
Obtain a clean catch mid-stream specimen
16. The nurse is assisting the mother of a child with
phenylketonuria (PKU) to select foods that are in keeping with the
child’s dietary restrictions. Which foods are contraindicated for this
child?
Foods sweetened with aspartame
17. Before preparing a client for the first surgical case of the day,
, a part-time scrub nurse asks the circulating nurse if a 3 minute
surgical hand scrub is adequate preparation for this client. Which
response should the circulating nurse provide?
Direct the nurse to continue the surgical hand scrub for a 5
minute duration
18. Which breakfast selection indicates that the client understands
the nurse’s instructions about the dietary management of
osteoporosis?
Bagel with jelly and skim milk
19. The charge nurse of a critical care unit is informed at the
beginning of the shift that less than the optimal number of registered
nurses will be working that shift. In planning assignments, which client
should receive the most care hours by a registered nurse (RN)?
An 82-year-old client with Alzheimer’s disease newly-fractures
femur who has a Foley catheter and soft wrist restrains applied
20. A mother brings her 6-year-old child, who has just stepped on a
rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes
that the nail went through the shoe and pierced the bottom of the
child’s foot. Which action should the nurse implement first?
Cleanse the foot with soap and water and apply an
antibiotic ointment
Provide teaching about the need for a tetanus booster within the
next 72 hours.
have the mother check the child's temperature q4h for the next
24 hours
transfer the child to the emergency department to receive
a gamma globulin injection
21. The mother of an adolescent tells the clinic nurse, “My son has
athlete’s foot, I have been applying triple antibiotic ointment for two
days, but there has been no improvement.” What instruction should
the nurse provide?
Stop using the ointment and encourage complete drying of the
feet and wearing clean socks.
22. A 26-year-old female client is admitted to the hospital for
treatment of a simple goiter, and levothyroxine sodium (Synthroid)
is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences
Bradycardia and constipation
Lethargy and lack of appetite
Muscle cramping and dry, flushed skin
Palpitations and shortness of breath
23. A client with a history of heart failure presents to the clinic with a
nausea, vomiting, yellow vision and palpitations. Which finding is most
important for the nurse to assess to the client?
Obtain a list of medications taken for cardiac history
24. The healthcare provider prescribes an IV solution of isoproterenol
(Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should
, program the infusion pump to deliver how many ml/hour? (Enter
numeric value only.)
75
Rationale: Convert mg to mcg and use the formula D/H x Q.
300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour
25. The pathophysiological mechanism are responsible for ascites
related to liver failure? (Select all that apply)
Fluid shifts from intravascular to interstitial area due to decreased
serum protein
Increased hydrostatic pressure in portal circulation
increases fluid shifts into abdomen
Increased circulating aldosterone levels that increase sodium and
water retention
26. The nurse is auscultating a client’s heart sounds. Which
description should the nurse use to document this sound? (Please
listen to the audio first to select the option that applies)
Murmur
Rationale: A murmur is auscultated as a swishing sound that is
associated with the blood turbulence created by the heart or
valvular defect.
27. The healthcare provider prescribes celtazidime (Fortax) 35 mg
every 8 hours IM for an infant. The 500 mg vial is labeled with the
instruction to add 5.3 ml diluent to provide a concentration of 100
mg/ml. How many ml should the nurse administered for each dose?
(Enter numeric value only. If rounding is required, round to the
nearest tenth)
0.4
rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
28. The nurse notes that a client has been receiving
hydromorphone (Dilaudid) every six hours for four days. What
assessment is most important for the nurse to complete?
Auscultate the client's bowel sounds
Observe for edema around the ankles
Measure the client’s capillary glucose level
Count the apical and radial pulses simultaneously
Rationale: hydromorphone is a potent opioid analgesic that
slows peristalsis and frequently causes constipation, so it is
most important to Auscultate the client's bowel sounds
29. A female client is admitted with end stage pulmonary disease
is alert, oriented, and complaining of shortness of breath. The client
tells the nurse that she wants “no heroic measures” taken if she
stops breathing, and she asks the nurse to document this in her
medical record. What action should the nurse implement?
Ask the client to discuss “do not resuscitate” with her healthcare
provider
30. A client is receiving a full strength continuous enteral tube
feeding at 50 ml/hour and has developed diarrhea. The client has a
new prescription to change the feeding to half strength. What
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