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HESI RN Exit Exam WITH COMPLETE ANSWERS 1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour after admissio17,01 €
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HESI RN Exit Exam WITH COMPLETE ANSWERS 1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour after admissio
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HESI RN Exit
HESI RN Exit Exam WITH COMPLETE ANSWERS
1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blo...
1. A male client with stomach cancer returns to the unit following a total gastrectomy. He
has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75
mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the
suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is
78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the
nurse implement first? - <<ANSWERS>>d. Increase the infusion rate of Lactated
Ringer's solution.
2. an adult male who fell 20 feet from the roof of this home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). the nurse notes that the
suction control chamber is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of
bright red blood is measured in the collection chamber. Which intervention should the
nurse implement? - <<ANSWERS>>a. Add sterile water to the suction control chamber.
3. A client who received hemodialysis yesterday is experiencing a blood pressure of
200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute.
The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen
saturation on room air of 89%. Which action should the nurse take first? -
<<ANSWERS>>c. Begin supplemental oxygen.
4. A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation. Based on the client's admitting diagnosis, which findings require
immediate action by the nurse? (Select all that apply) - <<ANSWERS>>Headache and
tremors
Irregular heart rate
pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding is the best indicator of hydration that the nurse should report to the
healthcare provider? - <<ANSWERS>>d. Skin tenting occurs when the client's forearm
is pinched.
,6. After an inservice about electronic health record (EHR) security and safeguarding
client information, the nurse observes a colleague going home with printed copies of
client information in a uniform pocket. Which action should the nurse take? -
<<ANSWERS>>a. File a detailed incident report with the specific hiring facility.
7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular
disease implemented in a rural health clinic. Which outcome indicate the program is
effective? - <<ANSWERS>>c. Clients who incurred disease complications promptly
received rehabilitation.
8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)
who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes
that the client is having increased shortness of breath with respirations at 23
breaths/minute. Which action should the nurse implement first? - <<ANSWERS>>d.
Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an
immediate investigation by the nurse? - <<ANSWERS>>When I get out of bed quickly, I
feel a little dizzy."
10. An older adult male who is in his early 70's is admitted to the emergency department
because of a COPD exacerbation. This client is struggling to breathe and the healthcare
team is preparing for endotracheal intubation. The spouse's wife, who is 30 years
younger than the client, asks the nurse to stop the procedure and provide the nurse a
copy of the client's living will. Which action should the nurse take? - <<ANSWERS>>b.
Notify the healthcare provider of the client's wishes.
11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a
client whose prescribed activity is bedrest with bedside commode use. The UAP reports
to the nurse that the client is so obese that the UAP feels unable to safely assist the
client in transferring from the bed to the bedside commode. How should the nurse
respond? - <<ANSWERS>>c. Advice the client to maintain bedrest so that safety can
be ensured.
12. A nurse determines that more than 25% of the students at a middle school are
overweight. The nurse presents the information at the parent-teacher meeting. What
action is most important for the nurse to include in the meeting? - <<ANSWERS>>c.
Distribute a shopping list of suggested healthy snack items.
, 13. After several months of chronic fatigue, morning stiffness, and join pain, a young
adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes
prednisone. Which education should the nurse provide the client with regard to taking
prednisone? - <<ANSWERS>>c. If sequential doses are missed, notify the healthcare
provider.
14. The psychiatric nurse is caring for clients on an adolescent unit. Which client
requires the nurse's immediate attention? - <<ANSWERS>>c. An 18-year-old client with
antisocial behavior who is being yelled at by other clients
15. The nurse caring for a child with mononucleosis can expect the child to exhibit
which symptoms? - <<ANSWERS>>b. Ear pain and fever.
16. A client arrives for an annual physical exam and complains of having calf pain. The
client's health history reveals peripheral atrial disease. Which question should the nurse
ask the client about expected finding related to chronic arterial symptoms? -
<<ANSWERS>>b. Does the calf pain occur when walking short distances?
17. The nurse is preparing to send a client to the cardiac catheterization lab for an
angioplasty. Which client report is most important for them to explore further prior to the
start of the procedure? - <<ANSWERS>>d. Experience facial swelling after eating crab.
18. The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and
scaly, and the mother reports that the child frequently scratches the lesions on the skin
to the point of causing bleeding. Which guideline is indicated for care of this child? -
<<ANSWERS>>b. Apply baby lotion to the skin twice daily.
19. A new mother on the postpartum unit runs out of the room screaming that her
newborn infant's crib is empty and the baby is missing. What action should the nurse
take first? - <<ANSWERS>>d. Match ID bands of all infants and mothers on the unit.
20. While providing a health history, a female client tells the clinic nurse that she
frequently thinks about hurting herself. Which question is most important for the nurse to
ask? - <<ANSWERS>>c. "Have you thought about taking your life?"
21. A college student brings a dorm roommate to the campus clinic because the
roommate has been talking to someone who is not present. The client tells the nurse
that the voices are saying, "kill, kill." What question should the nurse ask the client next?
- <<ANSWERS>>c. "Are you planning to obey the voices?"
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