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HESI EXIT Comprehensive PN Exam A
Questions and Answers 2023 (Verified Answers)
1.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?: A multiparous
client who is dilated 5 cm and 50% effaced
2.A client with human immunodeficiency virus (HIV) infection has white
lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin)
preparation is prescribed as a swish and swallow. Which information is mostimportant for the nurse to provide the client?: Oral hygiene should be
performed before the medication.
3.A client who is admitted with emphysema is having difficulty breathing.
In which position should the nurse place the client?: Sitting upright and
forward with both arms supported on an over the bed table
4.A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily.
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Today, at a routine clinic visit, the client’s serum potassium level is 4 mEq/L.What is the most likely cause of this client’s potassium level?: The client’s
renal function has affected his potassium level.
5.A registered nurse (RN) delivers telehealth services to clients via
electronic communication. Which nursing action creates the greatest risk forprofession- al liability and has the potential for a malpractice lawsuit?:
Sending medical records to health care providers via the Internet
- Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure
(ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when
the ICP is elevated.
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.: 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 the risks associated with
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opioid 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 of this disaster are not yet known. Which
instruction
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should the charge nurse give to the other staff members at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should 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.:
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 incoming
casualties are anticipated. (C) is poor utilization of 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 worsening. The nurse is unsure of the client’s
resuscitative status and needs to check the client’s medical record for
any advanced directives. Which action should the nurse implement?
A.Ask the UAP to check for the advanced directive while the nurse
completes the assessment.
B.Assign the UAP to complete the assessment while the nurse checks for
the advanced directive.
C.Check the medical record for the advanced directive and then complete
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HESI EXIT Comprehensive PN Exam B
Questions and Answers 2023 (Verified Answers)
- The nurse is caring for a client with a cerebrovascular accident (CVA)
who is receiving enteral tube feedings. Which task performed by the UAP
requires immediate intervention by the nurse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing
sheets C.Takes temperature using the axillary
method
D.Keeps head of bed elevated at 30 degrees:
B Rationale:
Positioning the head of the bed flat when enteral feedings are in
progress puts the client at risk for aspiration (B). The others are all
acceptable tasks performed by the UAP (A, C, and D). - When caring for a postsurgical client who has undergone multiple bloodtransfusions, which serum laboratory finding is of most concern to the
nurse? A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L:
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B Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum
potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The
others are normal findings (A, C, and D).
- Which vaccination should the nurse administer to a
newborn? A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine:
A Rationale:
The hepatitis B vaccination should be given to all newborns before
hospital dis- charge (A). HPV is not recommended until adolescence (B).
Varicella immunization begins at 12 months (C). Meningococcal vaccine is administered beginning at 2 years (D). - The nurse is caring for a client on the medical unit. Which task can
be delegated to unlicensed assistive personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a fingerstick blood glucose level.
C.Answer a family member’s questions about the client’s plan of care.
D.Teach the client side effects to report related to the current
medication regimen.: B
Rationale:
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Obtaining a fingerstick blood glucose level is a simple treatment and isan appropri- ate skill for UAP to perform (B). (A, C, and D) are skills thatcannot be delegated to UAP.
- The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which action(s) should
the nurse expect to implement? (Select all that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale
(NIHSS).
C.Assess the client for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
E.Initiate multidisciplinary consult for potential rehabilitation.:
B,C,E Rationale:
Neurologic assessment, including the NIHSS, is indicated for the client
receiving t-PA. This includes close monitoring for bleeding during and
after the infusion; if bleeding or other signs of neurologic impairment
occur, the infusion should be stopped (B, C, and E). Aspirin is
contraindicated with t-PA because it increases the risk for bleeding
(A). The administration of t-PA within 6 hours of symptoms is
concurrent with a diagnosis of a myocardial infarction and within 4.5
hours of symptoms is concurrent for a stroke (D). - When caring for a client in labor, which finding is most important to
report to the primary health care provider?
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A.Maternal heart rate, 90 beats/min.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F:
B Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B)because the average FHR at term is 140 beats/min and the normarange is 110 to beats/min 160. The others (A, C, and D) are normafindings for a woman in labor.
- The nurse is caring for a client with heart failure who develops
respiratory distress and coughs up pink frothy sputum. Which action
should the nurse take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler’s position with the legs down.
D.Obtain a chest X-ray.:
C Rationale:
Positioning the patient in a high Fowler’s position with dangling feet widecrease