1ST HESI EXIT EXAM BSN

1ST HESI EXIT EXAM BSN 2 The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? a. A peanut butter sandwich with soda and cookies. b. A tuna fish sandwich with chips and ice cream. c. Vegetable soup, crackers, and milk. d. A salad with three kinds of lettuce and fruit. 3 The nurse implements a primary prevention program for sexually transmitted diseases in a nurse managed health center. Which outcome indicates that the program was effective? A. Average client scores improved on specific risk factor knowledge test. B. More than half of at-risk client were diagnosed early in their process. C. New screening protocols were developed, validated, and implemented. D. Clients who incurred disease complications promptly received rehabilitation. 4 A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessments include blood pressure 85/45 mm Hg, oral temperature 98.6° F (37° C), pulse 124 beats/minute, and respirations 22 breaths/minute. Based on these data, the nurse formulates the first portion of a nursing problem as "Risk for injury". What term best expresses the "related to" portion of the nursing problem? a. head injury. b. infection. c. increased intracranial pressure. d. shock. 5 A nurse working on an endocrine unit should see which client first. a. An adolescent male with diabetes who is arguing about his insulin dose. b. An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44 mmol/l). c. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour. d. A client taking corticosteroids who has become disoriented in the last two hours. 6 Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of Type A Rh negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement? a. Transfuse Type A negative blood until Type AB negative is available. b. Recheck the clienfs hemoglobin, blood type, and Rh factor. c. Obtain additional consent for administration of Type A negative blood. d. Administer normal saline solution until Type AB negative is available. 7 An older client who lives alone in a two-story home is admitted after falling while shopping. X-rays reveal a fractured left hip. With no immediate family in the area, the client is concerned about the pets at home. Which interventions should the nurse implement? (Select au that apply.) A- Evaluate pain using a standard pain scale B- Alert social worker of client's concerns. C- Support left leg with two pillows. D- Palpate and mark pedal pulses. E- Assess ability to bear weight when standing 8 Which laboratory finding for an adult client is most critical for the nurse to report to the healthcare provider? (Click on the correct location on the chart. To change, click on a new location.) ▪ Serum Sodio 142 mEq/L (142 mmol/L) ▪ Postassium 3.9 mEq/L (3.9 mmol'/L) ▪ Serum glucose 62 mg/dl (3.4 mmdl/L) ▪ Blood urea nitrogen 18 mg/dl (6.4 mmol/L) 9 An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? a. Observe neck for jugular vein distention b. Notify healthcare provider to prepare for pericardiocentesis c. Asses for paradoxical blood pressure d. Monitor oxygen saturation (Sp02) via continuous pulse oximetry 10 The parent of a child born with a cleft lip asks the nurse to explain why this happened. The parent is concerned that they did something wrong that caused this to occur. Which response is most helpful? a. "You didn't do anything wrong." b. "This must be a very difficult time for you." c. "With surgery, your baby should have a full recovery. d. "Is there any particular reason why you think this is your fault? 11 After diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions? a. Chest physiotherapy should be performed twice a day before a meal. b. Administer a cough suppressant every 8 hours." c. Energy should be conserved by scheduling minimally strenuous activities." d. Maintain supplemental oxygen at 4 to 6 Uminute." 12 A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? (Select all that apply.) a. Auscultate bowel sounds in all quadrants. b. Review last partial thromboplastin time results. c. Assess characteristics of pain. d. Prepare to administer warfarin. e. Monitor stools for presence of blood. 13 The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan? a. Literacy level. b. Median age. c. Prevalent learning style. d. Percent with Internet access. 14 The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? a. Gradual onset of continuous eye pain and blurred vision. b. Recent change in the ability to read and drive after dark. c. Gray-white circle around the iris of both eyes. d. Cloudy opacity of the crystalline lens. 15 While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take? a. Inform the client that falls occur more often in the hospital than at home. b. Continue to obtain client data needed to complete the fall risk survey. c. Record a minimal risk for falls, documenting the client's statement. d. Place the client on a high fall risk protocol because of advanced age. 16 A client with gestational diabetes is being induced for labor. Which assessment is most important for the nurse to perform prior to increasing the oxytocin rate? a. Contraction pattern. b. Blood pressure. c. Fingerstick glucose. d. Vaginal exam. 17 A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dl (15 g/L). Which intervention is the priority for the nurse to implement? a. Ensure the client receives frequent small meals containing complete proteins. b. Recommend the use of support stockings to enhance venous return. c. Evaluate patency of the AV graft for resumption of hemodialysis. d. Instruct the client to continue to follow the prescribed rigid fluid restriction amounts. 18 Following a motor vehicle collision (MVC), an unrestrained client is admitted to the intensive care unit with altered mental status. The client has multiple rib fractures and bruising across the lower abdomen. Which assessment finding warrants immediate intervention by the nurse? (Please scroll and view each tab's information in the client's medical record before selecting the answer.) a. A large amount of gross hematuria. b. Several apnea episodes lasting ten seconds. c. Delayed peripheral capillary refill. d. Numbness of the left lower extremity. 19 Which client requires careful nursing assessment for signs and symptoms of hypermagnesemia? a. A client who developed hyperparathyroidism in late adolescence. b. A female client who is overzealous with her intake of simple carbohydrates. c. A middle-aged male client in renal failure following an unsuccessful kidney transplant. d. A young adult client with intractable vomiting from food poisoning. 20 An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In what order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.) a. Note date and time of the behavior b. Discuss the issue privately with the UAP. R/ NDPE c. Evaluate the UAP for signs of improvement. d. Plan for scheduled break times. 21 The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss. The client's daughter who lives close to her father tells the nurse that she will stop by daily to check on her father. Which interventions should the nurse implement? (Select all that apply.) a. Include the family in the discharge teaching. b. Face client when speaking. c. Encourage the client to attend reading classes. d. Speak loudly when teaching. e. Provide the daughter with written instructions. 22 A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response? a. "You are in a safe place. No one can get to you here. b. "There is no one who will hurt you." c. "What would you like to see me do to protect you? d. "You seem quite frightened right now. 23 The nurse is caring for an adolescent who fell 20 feet (6.1 meters) 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement? a. Inquire about food allergies and food likes and dislikes. b. Talk directly to the adolescent while providing care. c. Monitor vital signs and neuro status every 2 hours. d. Initiate open communication with the teen’s parents. 24 In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? a. Prepare the client to independently treat their disease process b. Reduce healthcare costs related to diabetic complications c. Enable clients to become active participating in controlling the disease process d. Increase client’s knowledge of the diabetic disease process and treatment options. 25 A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client requests an afternoon snack, which dietary choice should the nurse provide? a. Vanilla-flavored yogurt b. Low fat chocolate milk. c. Calcium fortified juice d. Cinnamon applesauce 26 During a postpartum assessment of a client who is 5 hours post vaginal delivery, the nurse determines the fundus is 3 finger breadths above the umbilicus and positioned to the client's left side. Which action should the nurse implement first? a. Encourage the client to void. b. Provide additional oral replacement fluids. c. Massage the fundus until firm. d. Catheterize for residual urinary volume.