A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse? correct answers A multiparous client who is dilated 5 cm and 50% effaced
A client with huma...
EXIT HESI - Comprehensive PN Exam A
Practice Questions
A nurse who has recently completed orientation is beginning work in the
labor andunit for the first time. When making assignments, which client
delivery
should the
charge nurse assign to this new nurse? correct answers A multiparous
client who
dilated 5 cmis and 50%
effaced
A client with human immunodeficiency virus (HIV) infection has white lesions
in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is
prescribed
swish as a
and swallow. Which information is most important for the nurse to
provide the
client? correct answers Oral hygiene should be performed before the
medication.
A client who is admitted with emphysema is having difficulty breathing. In
which position
should the nurse place the client? correct answers Sitting upright and
forward
arms with both
supported on an over the bed
table
A client with chronic renal insufficiency (CRI) is taking 25 mg of
hydrochlorothiazide
(HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine
clinic
the visit, serum potassium level is 4 mEq/L. What is the most likely
client's
cause ofpotassium
client's this level? correct answers The client's renal function has
affected his
potassium
level.
A registered nurse (RN) delivers telehealth services to clients via
electronic
communication. Which nursing action creates the greatest risk for
professional
and has the potential
liability for a malpractice lawsuit? correct answers
Sendingto
records medical
health care providers via the
Internet
Which pathophysiologic response supports the contraindication for
opioids, such
morphine, as
in clients with increased intracranial
pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when
the ICP is
elevate
d.
B.Higher doses of opioids are required when cerebral blood flow is
reduced by an
elevated
ICP.
C.Dysphoria from opioids contributes to altered levels of
consciousness with an
elevated
ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an
elevated
ICP. correct answers
D
The greatest risk associated with opioids such as morphine (D) is
respiratory
depression that causes an increase in Pco2, which increases ICP and masks
the early
,signs of intracranial bleeding in head injury. (A, B, and C) do not
support thewith
associated risksopioid use in a client with
increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending
disaster requiring
implementation of the hospital's disaster plan. Specific facts about the
nature ofare
disaster thisnot yet known. Which instruction should the charge nurse give
to themembers
staff other at this
time?
A.Prepare to evacuate the unit, starting with the
bedridden
B.UAPs shouldclients.
report to the emergency center to handle
transports.
C.The licensed staff should begin counting wheelchairs and IV poles on
the unit.
D.Continue with current assignments until more instructions are
received. correct
answers
D
When faced with an impending disaster, hospital personnel may be alerted
but should
continue with current client care assignments until further instructions are
received (D).
Evacuation is typically a response of last resort that begins with clients
who are most
able to ambulate (A). (B) is premature and is likely to increase the chaos
if incomingare anticipated. (C) is poor utilization of
casualties
personnel.
The nurse assesses a client while the UAP measures the client's vital signs.
The client's
vital signs change suddenly, and the nurse determines that the client's
condition is The nurse is unsure of the client's resuscitative status and
worsening.
needs
the to check
client's medical record for any advanced directives. Which action
should the nurse
implemen
t?
A.Ask the UAP to check for the advanced directive while the nurse
completes the
assessmen
t.
B.Assign the UAP to complete the assessment while the nurse checks for thed
advance
directiv
e.
C.Check the medical record for the advanced directive and then
complete the client
assessmen
t.D.Call for the charge nurse to check the advanced directive while
continuing
the to assess
client. correct
answers D
Because the client's condition is worsening, the nurse should remain with
the clientthe
continue andassessment while calling for help from the charge nurse to
client's
determine resuscitative
the status (D). (A and B) are tasks that must be completed
by acannot
and nurse be delegated to the UAP. (C) is
contraindicated.
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is
helpingWhich
nurse. the task is important for the nurse to perform, rather than
the UAP?
A.Remove the client's nail polish and
dentures.
B.Assist the client to the restroom to
void.
C.Obtain the client's height and
weight.
D.Offer the client emotional support. correct
answers D
, By using therapeutic techniques to offer support (D), the nurse can
determinethat
concerns anyneed
clientto be addressed. (A, B, and C) are all actions that can be
performed
by the UAP under the supervision of the
nurse.
Until the census on the obstetrics (OB) unit increases, an unlicensed
assistive
personnel (UAP) who usually works in labor and delivery and the newborn
nursery isto work on the postoperative unit. Which client would be best for
assigned
the charge
nurse to assign to this
UAP?
A.An adolescent who was readmitted to the hospital because of a
postoperative
infectio
nB.A woman with a new colostomy who requires discharge
teaching
C.A woman who had a hip replacement and may be transferred to the
home
D.A mancare whounit
had a cholecystectomy and currently has a nasogastric
tube set to suction correct
intermittent
answers
The chargeC nurse will be responsible for providing a report to the home
care unit if the (A). The client is infected and an employee who works on
transfer occurs
an OB unit
should be assigned to clean cases in case the employee is required to return
to the
unit OBThis requires the skills of a registered nurse (RN) to do discharge
(B).
teachingemotional
provide and support (D). This may require skills beyond the level of
this UAP.
A male client is admitted for observation after being hit on the head with a
baseball
Six hoursbat. after admission, the client attempts to crawl out of bed and
asks there
why the nurse
are so many bugs in his bed. His vital signs are stable, and
the pulse reading is 98% on room air. Which intervention should the nurse
oximeter
perform first?
A.Administer oxygen per nasal cannula at 2
L/min.
B.Plan to check his vital signs again in 30
minutes.
C.Notify the health care provider of the change in
mentalthe
D.Ask status.
client why he thinks there are bugs in the bed. correct
answers
One of theC earliest signs of increased intracranial pressure (ICP) is a change
in mental
status (C). It is important to act early and quickly when symptoms of
increased
occur. ICP his oxygen saturation is normal, the administration of
Because
oxygen
the (A) is not
top priority. Vital signs should be monitored frequently (B), but the
client's be
should confusion
reported immediately. (D) is not a useful
intervention.
The nurse is monitoring a client who is receiving bedside conscious
sedation with
midazolam hydrochloride (Versed). In assessing the client, the nurse
determines
the client has that
slurred speech with diplopia. Based on this finding, what action
should the
nurse
take?
A.Open the airway with a chin lift-head tilt
maneuver.
B.Obtain a fingerstick glucose
reading.
C.Administer flumazenil
(Romazicon).
D.Continue to monitor the client. correct
answers D
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