HESI RN 2024 EXIT EXAM v2 Latest Update 2023/2024 Verified Questions and Answers *** Photo of quiet injecting insulin into outter thigh. A) Demonstrate correct selection of the injection site. B) Advise the client to change the angle of the needle. C) Observe the injection site for signs of lipodystrophy. D) Provide a pair of exam gloves for the client to wear. - ✔✔ANSW✔✔A) Demonstrate correct selection of the injection site. The nurse is auscultating a clients lung sounds. Which description should the nurse use to document this sound? Please listen to the audio file to select the option that applies. A) High pitch squeeze. B) Rhonchi. C) High -pitched or fine crackles. D) Stridor. - ✔✔ANSW✔✔C) High -pitched or fine crackles. The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care? A) Maintain strict intake and output. B) Keep head of bed raised 45°. C) Excess warmth of extremities. D) Monitor blood glucose level. - ✔✔ANSW✔✔A) Maintain strict intake and output. The nurse is managing for clients in the ICU who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding? A) Diminished breath sounds in the right posterior base. B) Restrained and restless with a slow volume alarm sounding. C) High -pressure alarm sounds when client is coughing. D) An audible voice when client is trying to communicate. - ✔✔ANSW✔✔B) Restrained and restless with a slow volume alarm sounding. The nurse is managing the care of a client with Cushing syndrome. Which intervention should the nurse delegate to be unlicensed assistive personnel? SATA. A) Weigh the client and report any weight gain. B) Note and report the clients food and liquid intake during meals and snacks. C) Assess the client for weakness and fatigue. D) Evaluate the client for sleep disturbances. E) Report any client mention of pain or discomfort. - ✔✔ANSW✔✔A) Weigh the client and report any weight gain. B) Note and report the clients food and liquid intake during meals and snacks. E) Report any client mention of pain or discomfort. The nurse is planning care for a client with chronic kidney disease he was a resident of a long -term nursing facility. The client is anuric and has hemodialysis three times a week. Which intervention should the nurse include in the clients plan of care? A) Initiate toileting schedule. B) Provide her nails skin barrier cream. C) Encourage intake of high potassium foods. D) Monitor for signs of anemia - ✔✔ANSW✔✔A) Initiate toileting schedule. A child newly diagnosed with sickle cell anemia is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A) Instructions about how much fluid the child to drink daily. B) Referral for social services for the child and family. C) Signs of addiction to opioid pain medications. D) Information about nonpharmaceutical pain relief measures. - ✔✔ANSW✔✔A) Instructions about how much fluid the child to drink daily. A client admitted with COPD exacerbation is receiving assisted ventilation with CPAP. The clients vital signs are an oral temperature 98.8 F, a heart rate of 118 bpm, a respiratory rate of 46 breaths per minute, and a blood pressure of 176/92. While comple ting the pulmonary assessment, the clients oxygen saturation rating is 78% and he is difficult to arouse. Which action should the nurse implement? A) Increase the oxygen delivery by 10%. B) Administer PRN nebulizer treatment. C) Complete neurological assessment. D) Prepare for rapid sequence intubation. - ✔✔ANSW✔✔D) Prepare for rapid sequence intubation. A client arrives at the emergency department describing chest pain that began three hours earlier which has not subsided. To assess the quality of the clients chest pain. Which approach for the nurse use? A) Provide a numeric pain scale. B) Ask the client to describe the pain. C) Identify effective pain relief measures. D) Observe body language and movement. - ✔✔ANSW✔✔B) Ask the client to describe the pain. A client develops your to Caria on the trunk and neck shortly after a secondary infusion of pepper Sillen is initiated. In which order should the nurse implement these interventions? Document reaction of the drug. Contact the healthcare provider. Assess vital signs. Stop the infusion. Initiate an adverse event report. - ✔✔ANSW✔✔Stop the infusion. Assess vital signs. Contact the healthcare provider. Initiate an adverse event report. Document reaction to drug. A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare? A) IV administration of benztropine. B) IV administration of isotonic crystalloid fluid. C) PO administration of lorazepam. D) PO administration of divalproex. - ✔✔ANSW✔✔A) IV administration of benztropine. A client is being urgently transported to radiology for a CT scan after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube of 20 cm section. Which action is most important for the nurse to take? A) Secure the chest tube to the stretcher for transport. B) Keep the chest tube container below the site of insertion. C) Administer a PRN pain management prior to transport. D) Mark the amount of chest drainage on the container. - ✔✔ANSW✔✔B) Keep the chest tube container below the site of insertion. A client is receiving IV fluids by gravity infusion and exhibit signs of fluid volume overload. When assessing the clients IV delivery system, where should the nurse assess first? - ✔✔ANSW✔✔A I can't see all the pics. Use the clamp on the IV tubing. A client is receiving methylamine 800 mg PO three times a day. Which assessment should the nurse perform to assess the effectiveness of the medication? A) Bowel patterns. B) Pupillary response. C) Peripheral pulses. D) Oxygen saturation. - ✔✔ANSW✔✔A) Bowel patterns. Ulcerative colitis medication that helps reduce inflammation in the G.I.. A client receives a prescription for Aceta medicine 1000 mg PO every eight hours PRN for pain. The bottle is labeled acetaminophen for oral suspension, US P 500 mg per 15 mL. How many tablespoons should the nurse administer with each dose? (Enter numerical value only.) - ✔✔ANSW✔✔2 15 mL per tablespoon A client who is 65 kg receives a prescription for lorazepam 44 mcg/kg IV to be administered 20 minutes before a scheduled procedure. The medication is available in 2 mg/mL vial. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest 10th) - ✔✔ANSW✔✔1.4 A client who is receiving zidovudine reports the appearance of pinpoint, red, brown spots on the skin. Which result should the nurse report to the healthcare provider? A) Skin biopsy. B) Complete blood count. C) Allergy test. D) Electromyography. - ✔✔ANSW✔✔B) Complete blood count. Petechiae can occur due to low platelet counts. Zidovudine is used for HIV and can cause hematological toxicity, anemia neutropenia. A client with a history of hypertension and diabetes mellitus is admitted with uncontrolled a fib. The healthcare provider prefers synchronized cardioversion and prescribed a stat dose of dronedarone 400 mg PO. Which assessment finding warrants immediate i ntervention by the nurse?
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