HESI VERSION 4 | Questions with 100% Correct Answers | Verified | Updated 2024

1. A male client who had a transurethral resection of the prostate (TURP) today has a continuous bladder irrigation (CBI). The client requests pain medication for abdominal pain rated at "9" on a scale of 1 to 10. What action should the nurse take first? Administer prescribed PRN analgesic medication. Position him on the left side and slow the irrigation rate. Palpate his abdomen and check his urinary output. Assist him to ambulate to help pass flatus.: C. Palpate his abdomen and check his urinary output. 2. The mental health nurse takes several adolescent clients to the inpa- tient schoolroom. The teacher asks the nurse to stay and help one of the male clients who has attention-deficit hyperactivity disorder with his spelling assignment. Which goal is reasonable for this client to attain during this one-hour class? Completes at least one page of spelling. Follows directions the first time they are given. Sits quietly with peers and completes assignment. Shares his problems with others in the class.: A. Completes at least one page of spelling. 3. A client is receiving a standardized solution of heparin 25,000-units/250 ml of normal saline. The healthcare provider prescribes to increase the client's current infusion rate of heparin to 700 units/hour. How many ml/hour should the nurse program the infusion pump? Enter the numerical value only.: Using formula, D/H x Q, 700 units/hour 25,000 units x 25o ml = 7 ml/hour 4. A client is receiving the intravenous adrenergic agonist dobutamine (Dobutrex). In evaluating the client's reaction to the medication, which assess- ment finding indicates to the nurse that the medication is effective? The client denies chest pain or discomfort. The client had 160 ml urine output in 8 hours. The client's blood pressure is 110/70 mmHg. The client's posterior tibial pulses are 1+.: C. The client's blood pressure is 110/70 mmHg. 5. A client misses breakfast because of a two-hour hand washing ritual that is performed daily. What plan is most therapeutic for the nurse to implement? Meet with the client daily to discuss motivation for initiating the ritual. Wake the client early so the ritual can be completed before breakfast. Set limits on amount of time the client is allowed to perform the ritual. Socialize with the client during the ritual to demonstrate acceptance: B. Wake the client early so the ritual can be completed before breakfast. 6. Which discharge instruction should the nurse provide a client with heart failure who is taking digoxin (Lanoxin)? Avoid concurrent use of herbal products. Take Lanoxin with high-fiber foods. Restrict fluid intake to equal urine output. Check blood glucose level weekly.: A. Avoid concurrent use of herbal products. 7. The charge nurse in the Intensive Care Unit (ICU) needs to transfer a client to the medical unit so that a client from the Emergency Room can be admitted to ICU. Which client is best to consider? A 38-year-old with a myocardial infarction who is having multifocal prema- ture ventricular contractions. A 66-year-old with congestive heart failure who has 2+ pitting edema and is short of breath on exertion. A 58-year-old diagnosed with Guillain-Barre syndrome who is having diffi- culty breathing. An 80-year-old with a bleeding peptic ulcer who has a Hgb of 7 g/dl and coffee ground drainage from NG.: B. A 66-year-old with congestive heart failure who has 2+ pitting edema and is short of breath on exertion. 8. The nurse stops to render aid at the scene of a motor vehicle collision and finds a child about 6 months of age strapped into a car seat in the back seat of the car. After calming the infant with a pacifier, what action should the nurse take? Remove the infant from the car seat while stabilizing the neck. Assess the infant's ability to move arms and legs. Determine if pupils constrict when exposed to light. Lift the car seat out of the car with the infant strapped in it.: D. Lift the car seat out of the car with the infant strapped in it. 9. An unresponsive female victim of a motor vehicle collision is brought to the emergency department where it is determined that immediate surgery is required to save her life. The client is accompanied by a close friend, but no family members are available. Which intervention should the nurse implement? Obtain an emergency court order for life-saving surgery for the client. Prepare the client for surgery without a signed informed consent