ALL HESI EXIT Questions and Answers Test Bank; A+
Rated Guide (2022)
271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take?
Administer the medication as prescribed with a glass of water
272. Which client should the nurse assess frequently because of the risk for overflow incontinence? A client
Who is confused and frequently forgets to go to the bathroom
273. While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply)
Move obstacle away from client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure
274. A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care?
Observe for changes in level of consciousness.
275. An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required?
Increase ventilator rate.
276. The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide?
CPT should be performed more frequently, but at least an hour before meals.
277. The nurse is evaluating the diet teaching of a client with hypertension. What dinner
selection indicates that the client understands the dietary recommendation for hypertension?
Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie
278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care?
Fingerstick glucose assessment q6h with meals
Review with the client proper foot care and prevention of injury
Coordinate carbohydrate controlled meals at consistent times and intervals
Teach subcutaneous injection technique, site rotation and insulin management 279. Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse?
Muscle pain
280. While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood
pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement?
Provide supplemental oxygen
Auscultate bilateral lung fields
Reinforce occlusive CT dressing
281. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
Ensure that the knot can be quickly released.
282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media.
An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution?
Have the child lie with the ear up for one to two minute after installation.
283. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?
Restrict daily fluid intake.
284. The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next?
Leave the catheter in place and obtain a sterile catheter.
285. A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
Prepare the skin for procedure.
286. Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take?
Restrict unvaccinated children from attending school until measles outbreak is resolved.
287. A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement?
Continue with the plan of care for this client
288. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts?
Begin to show signs of improvement in affect 289. When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?
Check for a destined bladder
290. A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement?
Encourage popsicles and fluids of choice
291. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement?
Palpate the client's suprapubic area for distention
292. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include?
Divide the medication into two injection with volumes under 1ml
293. A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful?
Research indicates that mirror therapy is effective in reducing phantom limb pain
294. An older adult client with heart failure (HF) develops cardiac tamponade. The client
has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?
Notify healthcare provider to prepare for pericardiocentesis
295. A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take?
Ask the new person to move belonging to accommodate others
296. The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication?
Poor feeding and vomiting
Leakage of CSF from the incisional site
Abdominal distention
297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only)
8
298. In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care?
Evaluate closet proximal pulse. 299. The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take?
Remove the heating pads and place a soft blanket over the client's leg and feet.
300. A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client?
Plan volume-controlled evenly-space meal thorough the day
301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child
has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding?
Insensible loss of body fluids contributes to the hemoconcentration of serum solutes
302. During a Woman's Health fair, which assignment is the best for the Practical Nurse
(PN) who is working with a register nurse (RN)
Prepare a woman for a bone density screening
303. An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take?
Send family to the waiting area while the client's history is taking
304. An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority?
Imbalance nutrition
305. The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan?
Avoid crowds for first two months after surgery.
306. The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up is needed for problems associated with chronic hypoxia?
Image
307. A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement?
Assess compliance with routine prescriptions.
308. The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is
Three days postoperative colon resection receiving transfusion of packed RBCs.
309. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching?
Avoid straining at stool, bending, or lifting heavy objects.
310. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10
