1. a male client admitted the morning of his scheduled surgery tells the PN that he drank water last night. What intervention will the PN implement first? Correct Answer: Determine the amount of water and exact time it was taken
2. A client receives ondansetron prior to chemotherapy treatment.Ho...
HESI EXIT EXAM PN TEST BANK
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1. a male client admitted the morning of his scheduled surgery tells the PN that he drank water last
night. What intervention will the PN implement first? Correct Answer: Determine the amount of
water and exact time it was taken
2. A client receives ondansetron prior to chemotherapy treatment.How should the PN evaluate
this medication? Correct Answer: Monitor the client for nausea or vomiting following the
treatment
3. During morning rounds a client is admitted with OCD is in the...of the same table. What
intervention should the PN implement when approached? Correct Answer: Provide time for the
behavior then guide the client to other activities
4. The PN is caring for an older adult client who is confused and spends...factor contributes to an
increased risk for impaired skin integrity for this client? Correct Answer: Has increasing episodes
of urinary incontinence
5. The pn determines that a client with cirrhosis is experiencing peripheral..... take? Correct Answer:
Protect the clients feet from injury
6. A client is admitted to the postoperative surgical unit after a left lobectomy with two chest
tubes......observes the water-sealed chambers, set and prescribed suction of 20cm water. what
action should the PN implement? Correct Answer: Maintain system integrity and to promote
lung reexpansion
7. photo of chest and locating apical HR Correct Answer: just below the left nipple
8. At the end of a 12-hour shift the PN observes the urine in a clients drainage..what action should
the PN take next? Correct Answer: note the most recent white blood count
9. A client with a compound fracture of the left ankle is being discharged with a below the knee
cast....PN provide to the client prior to discharge? Correct Answer: never scratch under the cast
10. Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his
pain...what action should the PN implement first? Correct Answer: implement complementary
pain relief methods
11. A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in .... with one
or two word responses. the morning the PN observes that he. Which intervention is most
important for the PN to implement? Correct Answer: Measure appropriate vital signs
12. The PN is assisting an unsteady client to ambulate from the bed to the bath. client loses balance
and falls onto the bedside table. what action should the PN take first? Correct Answer: Stay
with the client and call for assistance
Med C
, 13. The PN is assisting a female client to obtain a voided specimen for uri...meatus. Which
intervention is performed next? Correct Answer: initiate the urine stream?
14. An 8-year old is placed in 90-90 traction for a fractured femur that resulted from...further action
by the PN? Correct Answer: weights are touching the foot of the bed
15. The PN is reviewing diet instructions with a female client who has hyper...she has increased her
intakes of protein and calories. What action should the PN take? Correct Answer: Encourage the
client to continue the dietary changes she has made
16. A 3-year old child returns to the pediatricians office for a postoperative visit after
having...procedure. The PN should expect to observe which behavior that indicates... Correct
Answer: plays doctor and nurse with the dolls
17. The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis and is
preparing for discharge from the hospital. What... Correct Answer: -why the fluid
measurements need to be recoded
18. -which food types are included when measuring fluid take
19. -what container to use for the most accurate measurement
20. A male client receives a prescription for 3,000 mg of medication daily, which is available...taken
twice daily in equal dosages.How many tablets should the PN... Correct Answer: 3
21. ... Correct Answer: request return visit for examination after her period when hormones are
lowest
22. A mother brings her 5-year old child to the clinic for school physical examinations. Which
assessment... PN that intergenerational violence may be occurring in the home? Correct
Answer: -The 6-year old son hits his younger sister during the interview
23. -the 10-year old daughter has circular burns on her trunk and legs
24. -the 3-year old has multiple bruises on the chest and both legs
25. A client has a prescription to discontinue intravenous therapy when the liter that is infusing at
150 mL per hour is...1200 the PN notes that there are 750 ml of solution remaining.At what time
should the nurse expect to discontinue the intravenous therapy? Correct Answer: 1700
26. the PN is caring for a client who had a total laryngectomy, left radical neck dissection... client is
receiving nasogastric tube feedings via an internal pump. today the rate of the feeding was
increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate
of the feeding? Correct Answer: gastric residual volumes
27. A new mother is breastfeeding her newborn for the first time after delivery and complains of
nipple pain...Based on the client complaint, what action should the PN take? Correct Answer:
Ensure that all the areolar tissue of the nipple is in the infants mouth.
28. Which site should the PN use when administering an injection of Rho (D) Immune negative
postpartum client? Correct Answer: deltoid
Med C
, 29. Before inserting medication into a clients vagina, what instructions should the pn... Correct
Answer: urinate until bladder is empty
30. An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which
information is best for the PN to provide? Correct Answer: A history of untreated gonnorhea
can lead to PID
31. A 28-year old client is in active labor and complains of a cramp in her leg. What intervention
should the PN implement? Correct Answer: extend the leg and flex the foot?
32. A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively
deal with breast engorgement and discomfort? Correct Answer: Wear a supportive bra at all
times
33. A client with schizophrenia reports auditory hallucinations when admitted to the hospital. PN to
include in the assessment of this client? Correct Answer: "what are the voices uttering?"
34. A young adult male tells the PN he has declared to change his hours at work so that he can...his
community. Which stage of Maslow's development is this young adult attempting to achieve?
Correct Answer: Self-actualiztion
35. A female client arrives to the clinic for an annal physical examination. when reviewing...the PN
that she takes herbs for high blood pressure instead of the prescribed..important for the PN to
reinforce with the client? Correct Answer: Explain risks associated with using herbs instead of
the prescribed antihypertensives.
36. A female Native American client who is receiving chemotherapy places a native artifact...the
health care provider removes the medicine wheel and tells the client "this type..hospital" what
intervention should the PN implement ? Correct Answer: Act as the clients advocate when
discussing the issue with the HCP
37. The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to
include in the nursing care plan? Correct Answer: watch the client for abnormal bleeding
38. ... Correct Answer: "it is better to obtain children acetaminophen to prevent possible side
effects from the aspirin "
39. A client is transferred to the surgical unit from the intensive care unit after evacuation of
bilateral..primary observation should the PN monitor? Correct Answer: neuro-vital signs related
to bleeding and intracranial pressure
40. The PN is working the day shift in a long term facility and is preparing..delegate to the UAP to
perform during the change of.. Correct Answer: total the clients PO intake, fill the water
pitchers, empty urinals and catheter bags.
41. While taking the vital signs of a older male client who takes psychotropic
medication...uncontrollable hand movements ad is excessively blinking his eyes, which
information.... Correct Answer: screening for tardive dyskinesia
Med C
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