{"id":117270,"date":"2023-08-28T12:04:06","date_gmt":"2023-08-28T12:04:06","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=117270"},"modified":"2023-08-28T12:04:09","modified_gmt":"2023-08-28T12:04:09","slug":"exit-hesi-test-banks-over-3000-qs-and-answers-spring-2023-exit-hesi-prep-distinction-level-assignment-has-everything","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2023\/08\/28\/exit-hesi-test-banks-over-3000-qs-and-answers-spring-2023-exit-hesi-prep-distinction-level-assignment-has-everything\/","title":{"rendered":"Exit HESI Test Banks (over 3000 Q&#8217;s and Answers ) spring 2023 \/ Exit HESI Prep Distinction Level Assignment Has everything."},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Comprehensive Exam<br>133- Cyclobenzaprine (Flexeril) is prescribed to a client with multiple sclerosis for the treatment of<br>muscle spasms. For which common side effect of this medication does the nurse monitor the client?<br>A. Diarrhea<br>B. Drowsiness Correct<br>C. Abdominal pain<br>D. Increased salivation<br>134 &#8211; A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains of<br>chest pain. The medication is ineffective, so the nurse prepares to administer a second dose. Before<br>administering the nitroglycerin, which action does the nurse make a priority?<br>A. Checking the client&#8217;s blood pressure Correct<br>B. Obtaining blood levels of cardiac enzymes<br>C. Asking the client whether he has a headache<br>D. Obtaining a 12-lead electrocardiogram (ECG)<br>135- Ciprofloxacin hydrochloride (Cipro) is prescribed to a client with a urinary tract infection. The<br>nurse, providing instruction about the medication, tells the client that it is best to take the medication:<br>A. With milk<br>B. With an antacid<br>C. 2 hours after meals Correct<br>D. With aluminum hydroxide<br>136.-<br>A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being<br>discharged from the hospital. Which statement by the client indicates a need for further instruction?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A. &#8220;I need to carry my nitroglycerin with me at all times.&#8221;<br>B. &#8220;I need to check my pulse before, during, and after exercise.&#8221;<br>C. &#8220;I need to avoid foods with saturated fats and foods high in cholesterol.&#8221;<br>D. &#8220;I need to participate in aerobic and weightlifting exercise three times a week.&#8221; Correct<br>137- A nurse provides information to a client who will be undergoing endoscopic retrograde<br>cholangiopancreatography (ERCP). The nurse tells the client that:<br>A. There is no need to fast (NPO status) before the procedure<br>B. The gallbladder is easily removed during this procedure if gallstones are found<br>C. The procedure is performed specifically to visualize the esophagus, stomach, and<br>duodenum<br>D. Dye may be injected during the procedure to permit visualization of the pancreatic and<br>biliary ducts Correct<br>138.ID: 383713175<br>A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium<br>(Lovenox) at home. The nurse teaches the client about the medication and tells the client to:<br>A. Store the medication in the refrigerator<br>B. Lie down to administer the subcutaneous injection Correct<br>C. Inject the medication in the upper outer aspect of the arm<br>D. Discard the medication if the solution appears pale yellow<br>139.ID: 383703667<br>An intravenous dose of adenosine (Adenocard) is prescribed for a client to treat Wolff-ParkinsonWhite syndrome. Which piece of equipment does the nurse make a priority of obtaining before<br>administering the medication?<br>A. Pulse oximeter<br>B. Cardiac monitor Correct<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">C. Blood-pressure cuff<br>D. Suction catheter and suction machine<br>140.ID: 383703619<br>A nurse provides information to a client with coronary artery disease (CAD) about smoking-cessation<br>measures. Which statement by the client indicates a need for further information?<br>A. &#8220;A community support group will help me quit.&#8221;<br>B. &#8220;I should drink a cup of coffee if I feel the urge to smoke.&#8221; Correct<br>C. &#8220;Relaxation exercises will help control my urge to smoke.&#8221;<br>D. &#8220;I can try chewing gum or sucking on hard candy if I feel the urge to smoke.&#8221;<br>141.ID: 383708584<br>Captopril (Capoten) is prescribed for a hospitalized client with heart failure. Which action is a priority<br>once the nurse has administered the first dose?<br>A. Checking the client&#8217;s apical heart rate<br>B. Maintaining the client on bed rest for 3 hours Correct<br>C. Monitoring the client for increased urine output<br>D. Checking the client&#8217;s breath sounds for decreased wheezing<br>142.ID: 383706680<br>A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and<br>cyanosis, and the nurse suspects pulmonary edema. The nurse would first:<br>A. Obtain a pulse oximetry reading<br>B. Raise the head of the client&#8217;s bed Correct<br>C. Administer a dose of morphine sulfate<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">D. Obtain a specimen for an arterial blood gas determination<br>143.ID: 383703665<br>The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which<br>intended effect of the medication does the nurse monitor the client?<br>A. Relief of pain<br>B. Relief of anxiety Correct<br>C. Decreased urine output<br>D. Increased blood pressure<br>144.ID: 383702944<br>A nurse is providing home care instructions to a client with coronary artery disease (CAD) who will<br>be discharged home and will be taking 1 aspirin daily. The nurse tells the client:<br>A. To stop the aspirin if nausea occurs Incorrect<br>B. To take the aspirin on an empty stomach<br>C. That the aspirin is a short-term treatment and will probably be discontinued in 2<br>weeks<br>145.ID: 383713112<br>A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the<br>nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg<br>position, on the left side. What action does the nurse take next?<br>A. Auscultating heart sounds<br>B. Clamping the intravenous catheter Correct<br>C. Checking the client&#8217;s blood pressure<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">HESI Exit Exam Over 700 Questions new 2019<br>latest 100%<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink<br>plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best followup action by the nurse.<br>a- Remind the client that it is also important to switch to decaffeinated coffee and tea.<br>b- Suggest that the client also plan to eat frequent small meals to reduce discomfort<br>c- Review with the client the need to avoid foods that are rich in milk and cream.<br>d- Reinforce this teaching by asking the client to list a dairy food that he might select.<\/li>\n\n\n\n<li>A male client with hypertension, who received new antihypertensive prescriptions at his last visit<br>returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158\/106 and he<br>admits that he has not been taking the prescribed medication because the drugs make him \u201cfeel<br>bad\u201d. In explaining the need for hypertension control, the nurse should stress that an elevated BP<br>places the client at risk for which pathophysiological condition?<br>a- Blindness secondary to cataracts<br>b- Acute kidney injury due to glomerular damage<br>c- Stroke secondary to hemorrhage<br>d- Heart block due to myocardial damage<\/li>\n\n\n\n<li>The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client<br>who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side<br>rails. What action should the nurse implement?<br>a. Ensure that the UAP has placed the pillows effectively to protect the client.<br>b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.<br>b. Assume responsibility for placing the pillows while the UAP completes another task.<br>c. Ask the UAP to use some of the pillows to prop the client in a side lying position.<\/li>\n\n\n\n<li>An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past<br>12 days. Which assessment finding requires immediate follow-up?<br>a- Describes life without purpose<br>b- Complains of nausea and loss of appetite<br>c- States is often fatigued and drowsy<br>d- Exhibits an increase in sweating.<\/li>\n\n\n\n<li>A 60-year-old female client with a positive family history of ovarian cancer has developed an<br>abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear<br>results are negative. What information should the nurse include in the client\u2019s teaching plan?<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">a- Further evaluation involving surgery may be needed<br>b- A pelvic exam is also needed before cancer is ruled out<br>c- Pap smear evaluation should be continued every six month<br>d- One additional negative pap smear in six months is needed.<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"6\">\n<li>A client who recently underwear a tracheostomy is being prepared for discharge to home. Which<br>instructions is most important for the nurse to include in the discharge plan?<br>a- Explain how to use communication tools.<br>b- Teach tracheal suctioning techniques<br>c- Encourage self-care and independence.<br>d- Demonstrate how to clean tracheostomy site.<\/li>\n\n\n\n<li>In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen<br>reservoir bag does not deflate completely during inspiration and the client\u2019s respiratory rate is 14<br>breaths \/ minute. What action should the nurse implement?<br>a- Encourage the client to take deep breaths<br>b- Remove the mask to deflate the bag<br>c- Increase the liter flow of oxygen<br>d- Document the assessment data<\/li>\n\n\n\n<li>During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action<br>should the nurse take first?<br>a- Give the client 4 ounces of orange juice<br>b- Call 911 to summon emergency assistance<br>c- Check the client for lacerations or fractures<br>d- Asses clients blood sugar level<\/li>\n\n\n\n<li>At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client<br>tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a<br>headache. Which action should the nurse take first?<br>a- Ensure preoperative lab results are available<br>b- Start prescribed IV with lactated Ringer\u2019s<br>c- Inform the anesthesia care provider<br>d- Contact the client\u2019s obstetrician.<\/li>\n\n\n\n<li>After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds.<br>To determine if an S3 heart sound is present, what action should the nurse take first?<br>a- Side the stethoscope across the sternum.<br>b- Move the stethoscope to the mitral site<br>c- Listen with the bell at the same location<br>d- Observe the cardiac telemetry monitor<\/li>\n\n\n\n<li>A 66-year-old woman is retiring and will no longer have a health insurance through her place of<br>employment. Which agency should the client be referred to by the employee health nurse for<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">health insurance needs?<br>a- Woman, Infant, and Children program<br>b- Medicaid<br>c- Medicare<br>d- Consolidated Omnibus Budget Reconciliation Act provision.<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"12\">\n<li>A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What<br>snack should the nurse instruct the client to take with the tetracycline?<br>a- Fruit-flavored yogurt.<br>b- Cheese and crackers.<br>c- Cold cereal with skim milk.<br>d- Toasted wheat bread and jelly<\/li>\n\n\n\n<li>Following a lumbar puncture, a client voices several complaints. What complaint indicated to the<br>nurse that the client is experiencing a complication?<br>a- \u201cI am having pain in my lower back when I move my legs\u201d<br>b- \u201cMy throat hurts when I swallow\u201d<br>c- \u201cI feel sick to my stomach and am going to throw up\u201d<br>d- I have a headache that gets worse when I sit up\u201d<\/li>\n\n\n\n<li>An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with<br>incontinence. Which action should the nurse implement?<br>a- Auscultate for renal bruits<br>b- Obtain a clean catch mid-stream specimen<br>c- Use a dipstick to measure for urinary ketone<br>d- Begin to strain the client\u2019s urine.<\/li>\n\n\n\n<li>The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in<br>keeping with the child\u2019s dietary restrictions. Which foods are contraindicated for this child?<br>a- Wheat products<br>b- Foods sweetened with aspartame.<br>c- High fat foods<br>d- High calories foods.<\/li>\n\n\n\n<li>Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the<br>circulating nurse if a 3-minute surgical hand scrub is adequate preparation for this client. Which<br>response should the circulating nurse provide?<br>a- Ask a more experience nurse to perform that scrub since it is the first time of the day<br>b- Validate the nurse is implementing the OR policy for surgical hand scrub<br>c- Inform the nurse that hand scrubs should be 3 minutes between cases.<br>d- Direct the nurse to continue the surgical hand scrub for a 5-minute duration.<\/li>\n\n\n\n<li>Which breakfast selection indicates that the client understands the nurse\u2019s instructions about the<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">dietary management of osteoporosis?<br>a- Egg whites, toast and coffee.<br>b- Bran muffin, mixed fruits, and orange juice.<br>c- Granola and grapefruit juice<br>d- Bagel with jelly and skim milk.<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"18\">\n<li>The charge nurse of a critical care unit is informed at the beginning of the shift that less than the<br>optimal number of registered nurses will be working that shift. In planning assignments, which<br>client should receive the most care hours by a registered nurse (RN)?<br>a- A 34-year -old admitted today after an emergency appendendectomy who has a peripheral<br>intravenous catheter and a Foley catheter.<br>b- A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and<br>vomiting due to electrolyte disturbance following a race.<br>c- A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal<br>cannula and has a saline-locked peripheral intravenous catheter.<br>d- An 82-year-old client with Alzheimer\u2019s disease newly-fractures femur who has a Foley catheter<br>and soft wrist restrains applied<\/li>\n\n\n\n<li>Z<br>a- Cleanse the foot with soap and water and apply an antibiotic ointment<br>b- Provide teaching about the need for a tetanus booster within the next 72 hours.<br>c- have the mother check the child&#8217;s temperature q4h for the next 24 hours<br>d- transfer the child to the emergency department to receive a gamma globulin injection<\/li>\n\n\n\n<li>The mother of an adolescent tells the clinic nurse, \u201cMy son has athlete\u2019s foot, I have been<br>applying triple antibiotic ointment for two days, but there has been no improvement.\u201d What<br>instruction should the nurse provide?<br>a- Antibiotics take two weeks to become effective against infections such as athlete\u2019s foot.<br>b- Continue using the ointment for a full week, even after the symptoms disappear.<br>c- Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration.<br>d- Stop using the ointment and encourage complete drying of the feet and wearing clean socks.<\/li>\n\n\n\n<li>A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and<br>levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the<br>prescribed dosage is too high for this client? The client experiences<br>a- Palpitations and shortness of breath<br>b- Bradycardia and constipation<br>c- Lethargy and lack of appetite<br>d- Muscle cramping and dry, flushed skin<\/li>\n\n\n\n<li>A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision<br>and palpitations. Which finding is most important for the nurse to assess to the client?<br>a- Determine the client\u2019s level of orientation and cognition<br>b- Assess distal pulses and signs of peripheral edema<br>c- Obtain a list of medications taken for cardiac history.<br>d- Ask the client about exposure to environmental heat.<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">HESI Exit RN Exam Over 700 Questions,<br>Answers Rationale New 2019\/2020 latest<br>100%<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Following discharge teaching, a male client with duodenal ulcer<br>tells the nurse the he will drink plenty of dairy products, such as<br>milk, to help coat and protect his ulcer. What is the best follow-up<br>action by the nurse?<br>a- Remind the client that it is also important to switch to decaffeinated<br>coffee and tea.<br>b- Suggest that the client also plan to eat frequent small meals to<br>reduce discomfort<br>c- Review with the client the need to avoid foods that are rich in<br>milk and cream.<br>d- Reinforce this teaching by asking the client to list a dairy food that he<br>might select.<br>Rationale: Diets rich in milk and cream stimulate gastric acid secretion<br>and should be avoided.<\/li>\n\n\n\n<li>A male client with hypertension, who received new<br>antihypertensive prescriptions at his last visit returns to the clinic<br>two weeks later to evaluate his blood pressure (BP). His BP is<br>158\/106 and he admits that he has not been taking the prescribed<br>medication because the drugs make him \u201cfeel bad\u201d. In explaining<br>the need for hypertension control, the nurse should stress that an<br>elevated BP places the client at risk for which pathophysiological<br>condition?<br>a- Blindness secondary to cataracts<br>b- Acute kidney injury due to glomerular damage<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">c- Stroke secondary to hemorrhage<br>d- Heart block due to myocardial damage<br>Rationale: Stroke related to cerebral hemorrhage is major risk for<br>uncontrolled hypertension.<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"3\">\n<li>The nurse observes an unlicensed assistive personnel (UAP)<br>positioning a newly admitted client who has a seizure disorder.<br>The client is supine and the UAP is placing soft pillows along the<br>side rails. What action should the nurse implement?<br>a- Ensure that the UAP has placed the pillows effectively to protect the<br>client.<br>b- Instruct the UAP to obtain soft blankets to secure to the side rails<br>instead of pillows.<br>a- Assume responsibility for placing the pillows while the UAP<br>completes another task.<br>b- Ask the UAP to use some of the pillows to prop the client in a side<br>lying position.<br>Rationale: The nurse should instruct the UAP to pad the side rails with<br>soft blankest because the use of pillows could result in suffocation and<br>would need to be removed at the onset of the seizure. The nurse can<br>delegate paddling the side rails to the UAP<\/li>\n\n\n\n<li>An adolescent with major depressive disorder has been taking<br>duloxetine (Cymbalta) for the past 12 days. Which assessment<br>finding requires immediate follow-up?<br>a- Describes life without purpose<br>b- Complains of nausea and loss of appetite<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">c- States is often fatigued and drowsy<br>d- Exhibits an increase in sweating.<br>Rationale: Cymbalta is a selective serotonin and norepinephrine<br>reuptake inhibitor that is known to increase the risk of suicidal<br>thinking in adolescents and young adults with major depressive<br>disorder. B, C and D are side effects<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"5\">\n<li>A 60-year-old female client with a positive family history of<br>ovarian cancer has developed an abdominal mass and is being<br>evaluated for possible ovarian cancer. Her Papanicolau (Pap)<br>smear results are negative. What information should the nurse<br>include in the client\u2019s teaching plan?<br>a- Further evaluation involving surgery may be needed<br>b- A pelvic exam is also needed before cancer is ruled out<br>c- Pap smear evaluation should be continued every six month<br>d- One additional negative pap smear in six months is needed.<br>Rationale: An abdominal mass in a client with a family history for<br>ovarian cancer should be evaluated carefully<\/li>\n\n\n\n<li>A client who recently underwear a tracheostomy is being<br>prepared for discharge to home. Which instructions is most<br>important for the nurse to include in the discharge plan?<br>a- Explain how to use communication tools.<br>b- Teach tracheal suctioning techniques<br>c- Encourage self-care and independence.<br>d- Demonstrate how to clean tracheostomy site.<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Rationale: Suctioning helps to clear secretions and maintain an open<br>airway, which is critical.<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"7\">\n<li>In assessing an adult client with a partial rebreather mask, the<br>nurse notes that the oxygen reservoir bag does not deflate<br>completely during inspiration and the client\u2019s respiratory rate is<br>14 breaths \/ minute. What action should the nurse implement?<br>a- Encourage the client to take deep breaths<br>b- Remove the mask to deflate the bag<br>c- Increase the liter flow of oxygen<br>d- Document the assessment data<br>Rational: reservoir bag should not deflate completely during inspiration<br>and the client\u2019s respiratory rate is within normal limits.<\/li>\n\n\n\n<li>During a home visit, the nurse observed an elderly client with<br>diabetes slip and fall. What action should the nurse take first?<br>a- Give the client 4 ounces of orange juice<br>b- Call 911 to summon emergency assistance<br>c- Check the client for lacerations or fractures<br>d- Asses clients blood sugar level<br>Rationale: After the client falls, the nurse should immediately assess for<br>the possibility of injuries and provide first aid as needed<\/li>\n\n\n\n<li>At 0600 while admitting a woman for a schedule repeat cesarean<br>section (C-Section), the client tells the nurse that she drank a cup<br>a coffee at 0400 because she wanted to avoid getting a headache.<br>Which action should the nurse take first?<br>a- Ensure preoperative lab results are available<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">ATI med surg EXIT EXAM<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will<br>drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is<br>the best follow-up action by the nurse?<br>\uf0b7 Review with the client the need to avoid foods that are rich in milk and cream<\/li>\n\n\n\n<li>A male client with hypertension, who received new antihypertensive prescriptions at his<br>last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP<br>is 158\/106 and he admits that he has not been taking the prescribed medication because<br>the drugs make him \u201cfeel bad\u201d. In explaining the need for hypertension control, the nurse<br>should stress that an elevated BP places the client at risk for which pathophysiological<br>condition?<br>\uf0b7 Stroke secondary to hemorrhage<\/li>\n\n\n\n<li>The nurse observes an unlicensed assistive personnel (UAP) positioning a newly<br>admitted client who has a seizure disorder. The client is supine and the UAP is placing<br>soft pillows along the side rails. What action should the nurse implement?<br>\uf0b7 Instruct the UAP to obtain soft blankets to secure to the side rails instead of<br>pillows.<\/li>\n\n\n\n<li>An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for<br>the past 12 days. Which assessment finding requires immediate follow-up?<br>\uf0b7 Describes life without purpose<\/li>\n\n\n\n<li>A 60-year-old female client with a positive family history of ovarian cancer has<br>developed an abdominal mass and is being evaluated for possible ovarian cancer. Her<br>Papanicolau (Pap) smear results are negative. What information should the nurse include<br>in the client\u2019s teaching plan?<br>\uf0b7 Further evaluation involving surgery may be needed<\/li>\n\n\n\n<li>A client who recently underwear a tracheostomy is being prepared for discharge to home.<br>Which instructions is most important for the nurse to include in the discharge plan?<br>\uf0b7 Teach tracheal suctioning techniques<\/li>\n\n\n\n<li>In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen<br>reservoir bag does not deflate completely during inspiration and the client\u2019s respiratory<br>rate is 14 breaths \/ minute. What action should the nurse implement?<br>\uf0b7 Document the assessment data<br>\uf0b7 Rational: reservoir bag should not deflate completely during inspiration and the<br>client\u2019s respiratory rate is within normal limits.<\/li>\n\n\n\n<li>During shift report, the central electrocardiogram (EKG) monitoring system alarms.<br>Which client alarm should the nurse investigate firs?<br>\uf0b7 Respiratory apnea of 30 seconds<\/li>\n\n\n\n<li>During a home visit, the nurse observed an elderly client with diabetes slip and fall. What<br>action should the nurse take first?<br>\uf0b7 Check the client for lacerations or fractures<\/li>\n\n\n\n<li>At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid<br>getting a headache. Which action should the nurse take first?<br>\uf0b7 Inform the anesthesia care provider<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"11\">\n<li>After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart<br>sounds. To determine if an S3 heart sound is present, what action should the nurse take<br>first?<br>\uf0b7 Listen with the bell at the same location<\/li>\n\n\n\n<li>A 66-year-old woman is retiring and will no longer have a health insurance through her<br>place of employment. Which agency should the client be referred to by the employee<br>health nurse for health insurance needs?<br>\uf0b7 Medicare<\/li>\n\n\n\n<li>A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset.<br>What snack should the nurse instruct the client to take with the tetracycline?<br>\uf0b7 Toasted wheat bread and jelly<\/li>\n\n\n\n<li>Following a lumbar puncture, a client voices several complaints. What complaint<br>indicated to the nurse that the client is experiencing a complication?<br>\uf0b7 \u201cI have a headache that gets worse when I sit up\u201d<br>\uf0b7 \u201cI am having pain in my lower back when I move my legs\u201d<br>\uf0b7 \u201cMy throat hurts when I swallow\u201d<br>\uf0b7 \u201cI feel sick to my stomach and am going to throw up\u201d<\/li>\n\n\n\n<li>An elderly client seems confused and reports the onset of nausea, dysuria, and urgency<br>with incontinence. Which action should the nurse implement?<br>\uf0b7 Obtain a clean catch mid-stream specimen<\/li>\n\n\n\n<li>The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods<br>that are in keeping with the child\u2019s dietary restrictions. Which foods are contraindicated<br>for this child?<br>\uf0b7 Foods sweetened with aspartame<\/li>\n\n\n\n<li>Before preparing a client for the first surgical case of the day, a part-time scrub nurse<br>asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for<br>this client. Which response should the circulating nurse provide?<br>\uf0b7 Direct the nurse to continue the surgical hand scrub for a 5 minute duration<\/li>\n\n\n\n<li>Which breakfast selection indicates that the client understands the nurse\u2019s instructions<br>about the dietary management of osteoporosis?<br>\uf0b7 Bagel with jelly and skim milk<\/li>\n\n\n\n<li>The charge nurse of a critical care unit is informed at the beginning of the shift that less<br>than the optimal number of registered nurses will be working that shift. In planning<br>assignments, which client should receive the most care hours by a registered nurse (RN)?<br>\uf0b7 An 82-year-old client with Alzheimer\u2019s disease newly-fractures femur who has a<br>Foley catheter and soft wrist restrains applied<\/li>\n\n\n\n<li>A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the<br>pediatrician\u2019s office. Upon inspection, the nurse notes that the nail went through the shoe<br>and pierced the bottom of the child\u2019s foot. Which action should the nurse implement<br>first?<br>\uf0b7 Cleanse the foot with soap and water and apply an antibiotic ointment<br>\uf0b7 Provide teaching about the need for a tetanus booster within the next 72 hours.<br>\uf0b7 have the mother check the child&#8217;s temperature q4h for the next 24 hours<br>\uf0b7 transfer the child to the emergency department to receive a gamma globulin<br>injection<\/li>\n\n\n\n<li>The mother of an adolescent tells the clinic nurse, \u201cMy son has athlete\u2019s foot, I have been<br>applying triple antibiotic ointment for two days, but there has been no improvement.\u201d<br>What instruction should the nurse provide?<br>\uf0b7 Stop using the ointment and encourage complete drying of the feet and wearing<br>clean socks.<\/li>\n\n\n\n<li>A 26-year-old female client is admitted to the hospital for treatment of a simple goiter,<br>and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the<br>nurse that the prescribed dosage is too high for this client? The client experiences<br>\uf0b7 Bradycardia and constipation<br>\uf0b7 Lethargy and lack of appetite<br>\uf0b7 Muscle cramping and dry, flushed skin<br>\uf0b7 Palpitations and shortness of breath<\/li>\n\n\n\n<li>A client with a history of heart failure presents to the clinic with a nausea, vomiting,<br>yellow vision and palpitations. Which finding is most important for the nurse to assess to<br>the client?<br>\uf0b7 Obtain a list of medications taken for cardiac history<\/li>\n\n\n\n<li>The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250<br>ml of D5W at 300 mcg\/hour. The nurse should program the infusion pump to deliver how<br>many ml\/hour? (Enter numeric value only.)<br>\uf0b7 75<br>\uf0b7 Rationale: Convert mg to mcg and use the formula D\/H x Q. 300 mcg\/hour \/<br>1,000 mcg x 250 ml = 3\/1 x 25 = 75 ml\/hour<\/li>\n\n\n\n<li>The pathophysiological mechanism are responsible for ascites related to liver failure?<br>(Select all that apply)<br>\uf0b7 Fluid shifts from intravascular to interstitial area due to decreased serum protein<br>\uf0b7 Increased hydrostatic pressure in portal circulation increases fluid shifts into<br>abdomen<br>\uf0b7 Increased circulating aldosterone levels that increase sodium and water retention<\/li>\n\n\n\n<li>The nurse is auscultating a client\u2019s heart sounds. Which description should the nurse use<br>to document this sound? (Please listen to the audio first to select the option that applies)<br>\uf0b7 Murmur<br>\uf0b7 Rationale: A murmur is auscultated as a swishing sound that is associated with the<br>blood turbulence created by the heart or valvular defect.<\/li>\n\n\n\n<li>The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an<br>infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a<br>concentration of 100 mg\/ml. How many ml should the nurse administered for each dose?<br>(Enter numeric value only. If rounding is required, round to the nearest tenth)<br>\uf0b7 0.4<br>\uf0b7 rationale: 35mg\/100mg x 1 = 0.35 = 0.4 ml<\/li>\n\n\n\n<li>The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six<br>hours for four days. What assessment is most important for the nurse to complete?<br>\uf0b7 Auscultate the client&#8217;s bowel sounds<br>\uf0b7 Observe for edema around the ankles<br>\uf0b7 Measure the client\u2019s capillary glucose level<br>\uf0b7 Count the apical and radial pulses simultaneously<br>\uf0b7 Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and<br>frequently causes constipation, so it is most important to Auscultate the client&#8217;s<br>bowel sounds<\/li>\n\n\n\n<li>A female client is admitted with end stage pulmonary disease is alert, oriented, and<br>complaining of shortness of breath. The client tells the nurse that she wants \u201cno heroic<br>measures\u201d taken if she stops breathing, and she asks the nurse to document this in her<br>medical record. What action should the nurse implement?<br>\uf0b7 Ask the client to discuss \u201cdo not resuscitate\u201d with her healthcare provider<\/li>\n\n\n\n<li>A client is receiving a full strength continuous enteral tube feeding at 50 ml\/hour and has<br>developed diarrhea. The client has a new prescription to change the feeding to half<br>strength. What intervention should the nurse implement?<br>\uf0b7 Add equal amounts of water and feeding to a feeding bag and infuse at 50ml\/hour<\/li>\n\n\n\n<li>A female client reports that her hair is becoming coarse and breaking off, that the outer<br>part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up<br>question is best for the nurse to ask?<br>\uf0b7 Have you noticed any changes in your fingernails?<br>\uf0b7 Rationale: The pattern of reported manifestations is suggestive of hypothyroidism<\/li>\n\n\n\n<li>After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites<br>and malnutrition. The client is drowsy but responding to verbal stimuli and reports<br>recently spitting up blood. What assessment finding warrants immediate intervention by<br>the nurse?<br>\uf0b7 Capillary refill of 8 seconds<br>\uf0b7 bruises on arms and legs<br>\uf0b7 round and tight abdomen<br>\uf0b7 pitting edema in lower legs<\/li>\n\n\n\n<li>After the nurse witnesses a preoperative client sign the surgical consent form, the nurse<br>signs the form as a witness. What are the legal implications of the nurse\u2019s signature on<br>the client\u2019s surgical consent form? (Select all that apply)<br>\uf0b7 The client voluntarily grants permission for the procedure to be done<br>\uf0b7 The client is competent to sign the consent without impairment of judgment<br>\uf0b7 The client understands the risks and benefits associated with the procedure<\/li>\n\n\n\n<li>Following surgery, a male client with antisocial personality disorder frequently requests<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">HESI 68 TEST BANK MID LPN RN<br>2020 KEY WORDS &amp; ANSWER(S)<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Chinese-American patient going in for emergency surgery within 24 hours &#8211; interpreter<\/li>\n\n\n\n<li>Infant with normal vitals, axillary temp low &#8211; place under warmer<\/li>\n\n\n\n<li>Baby &#8211; protect the sac and place on abdomen<\/li>\n\n\n\n<li>Osteoarthritis &#8211; vitamin C?<\/li>\n\n\n\n<li>DM pump &#8211; pt needs to know how to calibrate and work bolus<\/li>\n\n\n\n<li>Mother gives pt iron with 2 oz. orange juice &#8211; tell mother she did it correctly<\/li>\n\n\n\n<li>Increased BMI &#8211; waist circumference<\/li>\n\n\n\n<li>PTSD &#8211; put pt in a room away from stimulus<\/li>\n\n\n\n<li>PTSD &#8211; show pt where the quiet room is when they first arrive<\/li>\n\n\n\n<li>Antabuse &#8211; no alcohol for 12 hours prior to beginning the medication<\/li>\n\n\n\n<li>Which wound would nurse assess first &#8211; laceration<\/li>\n\n\n\n<li>Pt crying about miscarriage &#8211; give tissue let her sit quietly<\/li>\n\n\n\n<li>Pt in employee health for routine hypertension, states he wants to kill coworker &#8211; see if pt<br>has a weapon<\/li>\n\n\n\n<li>Women pregnant and smoking &#8211; go to help group for emotional support<\/li>\n\n\n\n<li>NMS &#8211; check vital signs<\/li>\n\n\n\n<li>Left heart failure &#8211; fatigue<\/li>\n\n\n\n<li>To determine if pt is on one-to-one &#8211; if they\u2019re going into other pt\u2019s rooms<\/li>\n\n\n\n<li>Pt on steroids asks why they need sliding scale &#8211; steroids and infection increase sugars<\/li>\n\n\n\n<li>Lasix &#8211; check electrolytes<\/li>\n\n\n\n<li>Glomerulonephritis &#8211; reduce sodium intake and no excess water consumption<\/li>\n\n\n\n<li>Bulk laxative &#8211; drink additional water after taking medication<\/li>\n\n\n\n<li>Pt ambulating in hallway &#8211; HR stable before and after<\/li>\n\n\n\n<li>\u201cActivity intolerance\u201d outcome &#8211; pt ambulates without discomfort<\/li>\n\n\n\n<li>HR increased 20 at 2 hour checks &#8211; look for cause of increased HR<\/li>\n\n\n\n<li>Unilateral knee replacement pain &#8211; PCA pump<\/li>\n\n\n\n<li>SATA iron &#8211; spinach option, beans option<\/li>\n\n\n\n<li>Pregnancy women priority dx &#8211; r\/o injury r\/t uterine atony<\/li>\n\n\n\n<li>Pitocin after delivery &#8211; promote uterine contractions<\/li>\n\n\n\n<li>Diabetes with shiny legs &#8211; check pedal pulse<\/li>\n\n\n\n<li>Evisceration &#8211; sterile saline and gauze<\/li>\n\n\n\n<li>Isotonic solution &#8211; clean without tissue damage<\/li>\n\n\n\n<li>NG tube with intermittent low suction &#8211; damp cotton swab in pt\u2019s mouth<\/li>\n\n\n\n<li>Broca\u2019s area &#8211; give pt extra time for expression<\/li>\n\n\n\n<li>Pt with HIV value indicates likely to develop infection &#8211; CD4+<\/li>\n\n\n\n<li>Palpating BP &#8211; inflate to 120 (+30 from where pulse stop)<\/li>\n\n\n\n<li>RLQ with N\/V, what do you do last &#8211; palpate<\/li>\n\n\n\n<li>Subjective response for pt with orthopnea &#8211; sleeps on 3 pillows at night<\/li>\n\n\n\n<li>Anorexic pt wants to work in cafeteria &#8211; recommend they work as receptionist<\/li>\n\n\n\n<li>Math &#8211; 1.7<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Pharmacology Exit HESI<br>Nurse should observe most closely for drug toxicity when a client<br>receives med that has what characteristic<br>Narrow therapeutic index<br>Nurse is conducting DC teaching about anti-anxiety drug diazepam<br>(valium)<br>Evaluate the ingredients of all over-the-counter drugs for alcohol<br>content<br>Nursing instruction most important for patient on Zyloprim<br>Increase fluid intake<br>Client getting Tofranil (Imipramine)<br>Give medication at night<br>Magnesium antidote<br>Calcium gluconate<br>Patient with hyperthyroidism taking inderal (propanalol)<br>Decreases pulse rate<br>Medication dosing-heparin 25000 units at 7ml\/hr doctor changed rate to<br>900 units what is the<br>Mls\/hr<br>Med was ordered 100mg in 4 divided doses in 24 hours available in<br>25mg, how many will you give every 6 hours<br>1<br>Patient on benzos<br>Answer is not narcan<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Patient Dx with bipolar-how to know if meds are effective<br>Family states patient is doing better with manic phases<br>Patient on Heparin going for surgery in a.m.,-priority<br>Assess patient for bleeds<br>Best time to give patient Abx (I think)<br>Time was like 1000, 1400, 1200, and 0400\u2026best to give around the<br>clock<br>Medication calculation-patient weighs equal to 16kg-order for Tamiflu<br>45mg BID<br>Must round up-answer is 3.8ml<br>Peptic ulcer med-what action<br>Histamine 2 agonist<br>Patient on folliculitis medication-what to teach<br>Drink with full glass of water<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Vasopressin<br>Vasoconstrictor<br>Know why Digoxin and Lasix are used together<br>Tamoxifen Citrate use and therapeutic outcome<br>Fosomax for osteoarthritis patient teaching<br>Rifampin for TB<br>Rusty-orange\/red colored urine and body fluids<br>Pyridium for bladder infection<br>Orange\/red\/pink urine<br>Stay in bed for 3 hours post first Ace Inhibitor dose<br>Avoid grapefruit juice with CCB<br>Lipitor (statins) in PM only-no grapefruit juice<br>Trough draw<br>30 minutes before scheduled dose<br>Peak draw<br>30-60 minutes after administration<br>Potassium sparing diuretic need to watch for hyperkalemia<br>Aldactone (spirinolactone)<br>Using bronchodilators before steroids for asthma teaching<br>Exhale completely, inhale deeply, hold breath for 10 seconds<br>Insulin can be kept at room temp<br>28 days<br>Drawing insulin<br>Clear (regular) first then cloudy (NPH)<br>Know the insulins and their peak\/onset (there are several Qs about this<br>in different formats)<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">HESI EXIT EXAM PN 2019 TEST BANK<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>a male client admitted the morning of his scheduled surgery tells the PN that he drank water last<br>night. What intervention will the PN implement first? Determine the amount of water and<br>exact time it was taken<\/li>\n\n\n\n<li>A client receives ondansetron prior to chemotherapy treatment.How should the PN evaluate<br>this medication? Monitor the client for nausea or vomiting following the treatment<\/li>\n\n\n\n<li>The PN is caring for an older adult client who is confused and spends\u2026factor contributes to an<br>increased risk for impaired skin integrity for this client? Has increasing episodes of urinary<br>incontinence<\/li>\n\n\n\n<li>The pn determines that a client with cirrhosis is experiencing peripheral\u2026.take? Protect the<br>clients feet from injury<\/li>\n\n\n\n<li>A client is admitted to the postoperative surgical unit after a left lobectomy with two chest<br>tubes\u2026\u2026observes the water-sealed chambers, set and prescribed suction of 20cm water\u2026what<br>action should the PN implement? Maintain system integrity and to promote lung<br>reexpansion<\/li>\n\n\n\n<li>photo of chest and locating apical HR just below the left nipple<\/li>\n\n\n\n<li>At the end of a 12-hour shift the PN observes the urine in a clients drainage..what action should<br>the PN take next? note the most recent white blood count<\/li>\n\n\n\n<li>Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his<br>pain\u2026what action should the PN implement first? implement complementary pain relief<br>methods<\/li>\n\n\n\n<li>A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in\u2026.with one<br>or two word responses. the morning the PN observes that he\u2026Which intervention is most<br>important for the PN to implement? Measure appropriate vital signs<\/li>\n\n\n\n<li>The PN is assisting a female client to obtain a voided specimen for uri\u2026meatus. Which<br>intervention is performed next? initiate the urine stream?<\/li>\n\n\n\n<li>An 8-year old is placed in 90-90 traction for a fractured femur that resulted from\u2026further action<br>by the PN? weights are touching the foot of the bed<\/li>\n\n\n\n<li>The PN is reviewing diet instructions with a female client who has hyper\u2026she has increased her<br>intakes of protein and calories. What action should the PN take?Encourage the client to<br>continue the dietary changes she has made<\/li>\n\n\n\n<li>The PN reviews the procedure for measuring fluid intake and output \u2026glomerulonephritis and is<br>preparing for discharge from the hospital. What\u2026 -why the fluid measurements need to<br>be recoded<\/li>\n\n\n\n<li>-which food types are included when measuring fluid take<\/li>\n\n\n\n<li>-what container to use for the most accurate measurement<\/li>\n\n\n\n<li>\u2026 request return visit for examination after her period when hormones are lowest<\/li>\n\n\n\n<li>A mother brings her 5-year old child to the clinic for school physical examinations. Which<br>assessment\u2026 PN that intergenerational violence may be occurring in the home? -The 6-year old<br>son hits his younger sister during the interview<\/li>\n\n\n\n<li>-the 10-year old daughter has circular burns on her trunk and legs<\/li>\n\n\n\n<li>-the 3-year old has multiple bruises on the chest and both legs<\/li>\n\n\n\n<li>A client has a prescription to discontinue intravenous therapy when the liter that is infusing at<br>150 mL per hour is\u20261200 the PN notes that there are 750 ml of solution remaining.At what time<br>should the nurse expect to discontinue the intravenous therapy? 1700<\/li>\n\n\n\n<li>the PN is caring for a client who had a total laryngectomy, left radical neck dissection\u2026 client is<br>receiving nasogastric tube feedings via an internal pump. today the rate of the feeding was<br>increased\u2026ml\/hr. What parameter should the PN use to evaluate the clients tolerate to the rate<br>of the feeding? gastric residual volumes<\/li>\n\n\n\n<li>A new mother is breastfeeding her newborn for the first time after delivery and complains of<br>nipple pain\u2026Based on the client complaint, what action should the PN take? Ensure that all<br>the areolar tissue of the nipple is in the infants mouth.<\/li>\n\n\n\n<li>Which site should the PN use when administering an injection of Rho (D) Immune negative<br>postpartum client? deltoid<\/li>\n\n\n\n<li>Before inserting medication into a clients vagina, what instructions should the pn\u2026 urinate<br>until bladder is empty<\/li>\n\n\n\n<li>An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which<br>information is best for the PN to provide? A history of untreated gonnorhea can lead to<br>PID<\/li>\n\n\n\n<li>A new mother is bottle feeding instead of breastfeeding her newborn, The PN\u2026most effectively<br>deal with breast engorgement and discomfort? Wear a supportive bra at all times<\/li>\n\n\n\n<li>A young adult male tells the PN he has declared to change his hours at work so that he can\u2026his<br>community. Which stage of Maslow&#8217;s development is this young adult attempting to achieve?<br>Self-actualiztion<\/li>\n\n\n\n<li>A female client arrives to the clinic for an annal physical examination. when reviewing\u2026the PN<br>that she takes herbs for high blood pressure instead of the prescribed..important for the PN to<br>reinforce with the client? Explain risks associated with using herbs instead of the<br>prescribed antihypertensives.<\/li>\n\n\n\n<li>A female Native American client who is receiving chemotherapy places a native artifact\u2026the<br>health care provider removes the medicine wheel and tells the client &#8220;this type..hospital&#8221; what<br>intervention should the PN implement ?Act as the clients advocate when discussing the issue<br>with the HCP<\/li>\n\n\n\n<li>The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to<br>include in the nursing care plan? watch the client for abnormal bleeding<\/li>\n\n\n\n<li>\u2026 &#8220;it is better to obtain children acetaminophen to prevent possible side effects from the<br>aspirin &#8220;<\/li>\n\n\n\n<li>A client is transferred to the surgical unit from the intensive care unit after evacuation of<br>bilateral..primary observation should the PN monitor? neuro-vital signs related to bleeding<br>and intracranial pressure<\/li>\n\n\n\n<li>The PN is working the day shift in a long term facility and is preparing..delegate to the UAP to<br>perform during the change of.. total the clients PO intake, fill the water pitchers, empty urinals<br>and catheter bags.<\/li>\n\n\n\n<li>While taking the vital signs of a older male client who takes psychotropic<br>medication\u2026uncontrollable hand movements ad is excessively blinking his eyes, which<br>information\u2026. screening for tardive dyskinesia<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Comprehensive Exam<br>133- Cyclobenzaprine (Flexeril) is prescribed to a client with multiple sclerosis for the treatment of<br>muscle spasms. For which common side effect of this medication does the nurse monitor the client?<br>A. Diarrhea<br>B. Drowsiness Correct<br>C. Abdominal pain<br>D. Increased salivation<br>134 &#8211; A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains of<br>chest pain. The medication is ineffective, so the nurse prepares to administer a second dose. Before<br>administering the nitroglycerin, which action does the nurse make a priority?<br>A. Checking the client&#8217;s blood pressure Correct<br>B. Obtaining blood levels of cardiac enzymes<br>C. Asking the client whether he has a headache<br>D. Obtaining a 12-lead electrocardiogram (ECG)<br>135- Ciprofloxacin hydrochloride (Cipro) is prescribed to a client with a urinary tract infection. The<br>nurse, providing instruction about the medication, tells the client that it is best to take the medication:<br>A. With milk<br>B. With an antacid<br>C. 2 hours after meals Correct<br>D. With aluminum hydroxide<br>136.-<br>A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being<br>discharged from the hospital. Which statement by the client indicates a need for further instruction?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A. &#8220;I need to carry my nitroglycerin with me at all times.&#8221;<br>B. &#8220;I need to check my pulse before, during, and after exercise.&#8221;<br>C. &#8220;I need to avoid foods with saturated fats and foods high in cholesterol.&#8221;<br>D. &#8220;I need to participate in aerobic and weightlifting exercise three times a week.&#8221; Correct<br>137- A nurse provides information to a client who will be undergoing endoscopic retrograde<br>cholangiopancreatography (ERCP). The nurse tells the client that:<br>A. There is no need to fast (NPO status) before the procedure<br>B. The gallbladder is easily removed during this procedure if gallstones are found<br>C. The procedure is performed specifically to visualize the esophagus, stomach, and<br>duodenum<br>D. Dye may be injected during the procedure to permit visualization of the pancreatic and<br>biliary ducts Correct<br>138.ID: 383713175<br>A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium<br>(Lovenox) at home. The nurse teaches the client about the medication and tells the client to:<br>A. Store the medication in the refrigerator<br>B. Lie down to administer the subcutaneous injection Correct<br>C. Inject the medication in the upper outer aspect of the arm<br>D. Discard the medication if the solution appears pale yellow<br>139.ID: 383703667<br>An intravenous dose of adenosine (Adenocard) is prescribed for a client to treat Wolff-ParkinsonWhite syndrome. Which piece of equipment does the nurse make a priority of obtaining before<br>administering the medication?<br>A. Pulse oximeter<br>B. Cardiac monitor Correct<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">C. Blood-pressure cuff<br>D. Suction catheter and suction machine<br>140.ID: 383703619<br>A nurse provides information to a client with coronary artery disease (CAD) about smoking-cessation<br>measures. Which statement by the client indicates a need for further information?<br>A. &#8220;A community support group will help me quit.&#8221;<br>B. &#8220;I should drink a cup of coffee if I feel the urge to smoke.&#8221; Correct<br>C. &#8220;Relaxation exercises will help control my urge to smoke.&#8221;<br>D. &#8220;I can try chewing gum or sucking on hard candy if I feel the urge to smoke.&#8221;<br>141.ID: 383708584<br>Captopril (Capoten) is prescribed for a hospitalized client with heart failure. Which action is a priority<br>once the nurse has administered the first dose?<br>A. Checking the client&#8217;s apical heart rate<br>B. Maintaining the client on bed rest for 3 hours Correct<br>C. Monitoring the client for increased urine output<br>D. Checking the client&#8217;s breath sounds for decreased wheezing<br>142.ID: 383706680<br>A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and<br>cyanosis, and the nurse suspects pulmonary edema. The nurse would first:<br>A. Obtain a pulse oximetry reading<br>B. Raise the head of the client&#8217;s bed Correct<br>C. Administer a dose of morphine sulfate<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">D. Obtain a specimen for an arterial blood gas determination<br>143.ID: 383703665<br>The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which<br>intended effect of the medication does the nurse monitor the client?<br>A. Relief of pain<br>B. Relief of anxiety Correct<br>C. Decreased urine output<br>D. Increased blood pressure<br>144.ID: 383702944<br>A nurse is providing home care instructions to a client with coronary artery disease (CAD) who will<br>be discharged home and will be taking 1 aspirin daily. The nurse tells the client:<br>A. To stop the aspirin if nausea occurs Incorrect<br>B. To take the aspirin on an empty stomach<br>C. That the aspirin is a short-term treatment and will probably be discontinued in 2<br>weeks<br>145.ID: 383713112<br>A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the<br>nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg<br>position, on the left side. What action does the nurse take next?<br>A. Auscultating heart sounds<br>B. Clamping the intravenous catheter Correct<br>C. Checking the client&#8217;s blood pressure<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">2020 PN HESI<br>Exit V1<br>Question 1<br>A school-age client with diabetes is placed on an intermediateacting insulin and regular insulin before breakfast and before<br>dinner. She will receive a snack of milk and cereal at bedtime.<br>What does the nurse tell the client the snack is intended to do?<br>You Selected:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Prevent late night hypoglycemia.<br>Correct response:<\/li>\n\n\n\n<li>Prevent late night hypoglycemia.<br>Question 2<br>A well-known public official of a small community is admitted to<br>the emergency department following an episode of chest pain.<br>Several nurses from the medical unit are aware of the admission and<br>access the official\u2019s electronic medical record to obtain a status<br>update. What is the best response for the nurse manager to make to<br>the nurses regarding this situation?<br>You Selected:<\/li>\n\n\n\n<li>\u201cAssessing the official\u2019s medical record is a breach of<br>confidentiality.\u201d<br>Correct response:<\/li>\n\n\n\n<li>\u201cAssessing the official\u2019s medical record is a breach of<br>confidentiality.\u201d<br>Question 3<br>A four-year-old child is diagnosed as having acute lymphocytic<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">leukemia. The white blood cell (WBC) count, especially the<br>neutrophil count, is low. What is the most important intervention the<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">nurse should teach the parents?<br>You Selected:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Protect your child from infections because his resistance to<br>infection is decreased<br>Correct response:<\/li>\n\n\n\n<li>Protect your child from infections because his resistance to<br>infection is decreased<br>Question 4<br>The nurse is caring for a client with influenza. The most effective<br>way to decrease the spread of microorganisms is:<br>You Selected:<\/li>\n\n\n\n<li>placing the client in isolation.<br>Correct response:<\/li>\n\n\n\n<li>washing the hands frequently.<br>Question 5<br>A client with a history of hypertension has been prescribed a new<br>antihypertensive medication and is reporting dizziness. Which is<br>the best way for the nurse to assess blood pressure?<br>You Selected:<\/li>\n\n\n\n<li>in the supine, sitting, and standing positions<br>Correct response:<\/li>\n\n\n\n<li>in the supine, sitting, and standing positions<br>Question 6<br>A client has a soft wrist-safety device. Which assessment finding<br>should the nurse investigate further?<br>You Selected:<\/li>\n\n\n\n<li>cool, pale fingers<br>Correct response:<\/li>\n\n\n\n<li>cool, pale fingers<br>Question 7<br>A nurse is caring for a female client before surgery. The client states<br>that she is glad that she will not be going through menopause as a<br>result of her surgery and is only having her uterus removed. The<br>nurse reviews the consent form and notes that the surgery is for a<br>total abdominal hysterectomy with a salpingo-oophorectomy. What<br>should the nurse do in this situation?<br>You Selected:<\/li>\n\n\n\n<li>Contact the surgeon to explain that the client needs further<br>clarification regarding surgery.<br>Correct response:<\/li>\n\n\n\n<li>Contact the surgeon to explain that the client needs further<br>clarification regarding surgery.<br>Question 8<br>A young client diagnosed with schizophrenia is talking with the<br>nurse and says, &#8220;You know, when I thought everyone was out to get<br>me, I was staying in my apartment all the time. Now, I would like to<br>get out and do things again.&#8221; What is the best initial response by the<br>nurse?<br>You Selected:<\/li>\n\n\n\n<li>&#8220;What activities did you enjoy in the past?&#8221;<br>Correct response:<\/li>\n\n\n\n<li>&#8220;What activities did you enjoy in the past?&#8221;<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Leadership\/Management Exit HESI<br>Finding a client sitting on the floor, nurse calls for help from UAP<br>Get a BP cuff<br>Assigning a UAP to assist client with personal care<br>Prescribed activity level<br>The ICU is full and short staffed, so nursing super informs charge nurse in the med dept that one nurse<br>must float to the ICU<br>Staff nurse who was cross-trained to work in the critical care dept<br>Charge nurse developing guidelines for a coronary care unit<br>The scope of standards of practice from the American nurses association<br>Which patient should be assigned to a nurse that is floated from maternity unit<br>Post op hysterectomy<br>There has been a major disaster. Triage nurse should give which patient priority<br>Cut over eye<br>Delegate to LPN<br>Dressing change<br>Move which patient to medical surgical unit<br>Patient with ABNL liver levels<br>One open bed in ICU but reserved for patient coming from PACU with respiratory problems, what to do<br>Take patient to ICU and arrange for respiratory patient to stay in PACU<br>UAP giving complete bath-which patient is more concern<br>Patient with dyspnea (SOB when lying flat)<br>Which one shows nurse manager being <strong>_<\/strong> (means no team work)<br>?<br>ER nurse getting moved to L&amp;D, what patient should leader assign<br>Patient with episiotomy infection<br>DNR<br>Notify the family<br>Against medical Advice (AMA)with and IV<br>RN removes IV, sign the document AMA form<br>Prescriptions-telephone<br>repeat order back to doctor to make sure it is correct<br>Assign UAP<br>hygiene, feeding, ADLS, ROM, ambulation<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Confidentiality-emergency department<br>don\u2019t give out information about patient, don\u2019t talk about patients condition in front of people, keep<br>records safe<br>Malpractice<br>negligence by professional personnel<br>Ex: buring client with hot heating pad, ignoring s\/s of bleeding, giving wrong medication<br>Patient bill of rights<br>show pt there bill of rights, they have the right to see their chart and anything regarding their care<br>Assign PN-scope of practice<br>No assessments, teaching (newly DX&#8217;d), IV&#8217;s, blood transfusions, no suicide patients, no critical<br>patients<br>Assignments-new grad<br>graduate nurse supervised by RN, what pt to give? Infusing antibiotic or choosing catheter port<br>Unsafe nurse<br>after nurse goes through rehab she can do her job regularly<br>Brain death-organ donation<br>if person is organ donor and is brain dead, organs can be donated<br>Critical lab value<br>high levels or low levels (know levels) potassium is a priority lab value<br>Fibromyalgia assistance<br>provide uninterrupted sleep and refer to pain specialist<br>RN role-assess<br>RN\u2019s assess not LPN or UAP<br>Med error- action<br>assess pt, incident report, notify doctor, document amt prescribed, and dosage given<br>MRSA room assigned<br>private room, contact isolation<br>Restraints<br>standards of care<br>Cultural<br>Native American POC<br>Know rules for Immunization permission<br>Priority care<br>Management<br>Ethical<br>Assign least care to UAP<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Leadership\/Management Exit HESI<br>Finding a client sitting on the floor, nurse calls for help from UAP<br>Get a BP cuff<br>Assigning a UAP to assist client with personal care<br>Prescribed activity level<br>The ICU is full and short staffed, so nursing super informs charge nurse in the med dept that one nurse<br>must float to the ICU<br>Staff nurse who was cross-trained to work in the critical care dept<br>Charge nurse developing guidelines for a coronary care unit<br>The scope of standards of practice from the American nurses association<br>Which patient should be assigned to a nurse that is floated from maternity unit<br>Post op hysterectomy<br>There has been a major disaster. Triage nurse should give which patient priority<br>Cut over eye<br>Delegate to LPN<br>Dressing change<br>Move which patient to medical surgical unit<br>Patient with ABNL liver levels<br>One open bed in ICU but reserved for patient coming from PACU with respiratory problems, what to do<br>Take patient to ICU and arrange for respiratory patient to stay in PACU<br>UAP giving complete bath-which patient is more concern<br>Patient with dyspnea (SOB when lying flat)<br>Which one shows nurse manager being <strong>_<\/strong> (means no team work)<br>?<br>ER nurse getting moved to L&amp;D, what patient should leader assign<br>Patient with episiotomy infection<br>DNR<br>Notify the family<br>Against medical Advice (AMA)with and IV<br>RN removes IV, sign the document AMA form<br>Prescriptions-telephone<br>repeat order back to doctor to make sure it is correct<br>Assign UAP<br>hygiene, feeding, ADLS, ROM, ambulation<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Confidentiality-emergency department<br>don\u2019t give out information about patient, don\u2019t talk about patients condition in front of people, keep<br>records safe<br>Malpractice<br>negligence by professional personnel<br>Ex: buring client with hot heating pad, ignoring s\/s of bleeding, giving wrong medication<br>Patient bill of rights<br>show pt there bill of rights, they have the right to see their chart and anything regarding their care<br>Assign PN-scope of practice<br>No assessments, teaching (newly DX&#8217;d), IV&#8217;s, blood transfusions, no suicide patients, no critical<br>patients<br>Assignments-new grad<br>graduate nurse supervised by RN, what pt to give? Infusing antibiotic or choosing catheter port<br>Unsafe nurse<br>after nurse goes through rehab she can do her job regularly<br>Brain death-organ donation<br>if person is organ donor and is brain dead, organs can be donated<br>Critical lab value<br>high levels or low levels (know levels) potassium is a priority lab value<br>Fibromyalgia assistance<br>provide uninterrupted sleep and refer to pain specialist<br>RN role-assess<br>RN\u2019s assess not LPN or UAP<br>Med error- action<br>assess pt, incident report, notify doctor, document amt prescribed, and dosage given<br>MRSA room assigned<br>private room, contact isolation<br>Restraints<br>standards of care<br>Cultural<br>Native American POC<br>Know rules for Immunization permission<br>Priority care<br>Management<br>Ethical<br>Assign least care to UAP<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">ALL HESI EXIT Questions and Answers<br>Test Bank; A+ Rated Guide (2022)<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"271\">\n<li>A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at<br>bedtime. What action should the nurse take?<br>(correct Answer- Administer the medication as prescribed with a glass of water<\/li>\n\n\n\n<li>Which client should the nurse assess frequently because of the risk for<br>overflow incontinence?<br>A client Who is confused and frequently forgets to go to the bathroom<\/li>\n\n\n\n<li>While monitoring a client during a seizure, which interventions should the<br>nurse implement? (Select all that apply)<br>(correct AnswerMove obstacle away from client<br>Monitor physical movements<br>Observe for a patent airway<br>Record the duration of the seizure<\/li>\n\n\n\n<li>A male client with a long history of alcoholism is admitted because of mild<br>confusion and fine motor tremors. He reports that he quit drinking alcohol and<br>stopped smoking cigarettes one month ago after his brother died of lung cancer.<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Which intervention is most important for the nurses to include in the client&#8217;s plan<br>of care?<br>(correct Answer- Observe for changes in level of consciousness.<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"275\">\n<li>An older adult female admitted to the intensive care unit (ICU) with a<br>possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%,<br>and respiratory rate of 12 breaths\/minute. The arterial blood gas (ABG) results<br>after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To<br>normalize the client&#8217;s ABG finding, which action is required?<br>correct Answer- Increase ventilator rate.<\/li>\n\n\n\n<li>The mother of the 12- month-old with cystic fibrosis reports that her child is<br>experiencing increasing congestion despite the use of chest physical therapy (CPT)<br>twice a day, and has also experiences a loss of appetite. What instruction should<br>the nurse provide?<br>(correct Answer- CPT should be performed more frequently, but at least an hour<br>before meals.<\/li>\n\n\n\n<li>The nurse is evaluating the diet teaching of a client with hypertension. What<br>dinner selection indicates that the client understands the dietary recommendation<br>for hypertension?<br>(correct Answer- Baked pork chop, applesauce, corn on the cob, 2% milk, and keylime pie<\/li>\n\n\n\n<li>A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic<br>episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units<br>subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h<br>are prescribed. What action should the nurse include in this client&#8217;s plan of care?<br>(correct Answer- Fingerstick glucose assessment q6h with meals<br>Review with the client proper foot care and prevention of injury<br>Coordinate carbohydrate controlled meals at consistent times and intervals<br>Teach subcutaneous injection technique, site rotation and insulin management<\/li>\n\n\n\n<li>Which problem reported by a client taking lovastatin requires the most<br>immediate fallow up by the nurse?<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">(correct Answer- Muscle pain<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"280\">\n<li>While assessing a client&#8217;s chest tube (CT), the nurse discovers bubbling in the<br>water seal chamber of the chest tube collection device. The client&#8217;s vital signs are:<br>blood pressure of 80\/40 mmHg, heart rate 120 beats\/minutes, respiratory rate 32<br>breaths\/minutes, oxygen saturation 88%. Which interventions should the nurse<br>implement?<br>(correct Answer- Provide supplemental oxygen<br>Auscultate bilateral lung fields<br>Reinforce occlusive CT dressing<\/li>\n\n\n\n<li>Before leaving the room of a confused client, the nurse notes that a half bow<br>knot was used to attach the client&#8217;s wrist restraints to the movable portion of the<br>client&#8217;s bed frame. What action should the nurse take before leaving the room?<br>(correct Answer- Ensure that the knot can be quickly released.<\/li>\n\n\n\n<li>Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis<br>media. An antipyrine and benzocaine-otic also prescribed for pain and<br>inflammation. What instruction should the nurse emphasize concerning the<br>installation of the antipyrine\/benzocaine otic solution?<br>(correct Answer- Have the child lie with the ear up for one to two minute after<br>installation.<\/li>\n\n\n\n<li>An older adult male is admitted with complications related to chronic<br>obstructive pulmonary disease (COPD). He reports progressive dyspnea that<br>worsens on exertion and his weakness has increased over the past month. The<br>nurse notes that he has dependent edema in both lower legs. Based on these<br>assessment findings, which dietary instruction should the nurse provide?<br>(correct Answer- Restrict daily fluid intake.<\/li>\n\n\n\n<li>The nurse inserts an indwelling urinary catheter as seen in the video what<br>action should the nurse take next?<br>(correct Answer- Leave the catheter in place and obtain a sterile catheter.<\/li>\n\n\n\n<li>A client with coronary artery disease who is experiencing syncopal episodes<br>is admitted for an electrophysiology study (EPS) and possible cardiac ablation<br>therapy. Which intervention should the nurse delegate to the unlicensed assistive<br>personnel (UAP)?<br>(correct Answer- Prepare the skin for procedure.<\/li>\n\n\n\n<li>Fallowing an outbreak of measles involving 5 students in an elementary<br>school, which action is most important for the school nurse to take? (correct<br>Answer- Restrict unvaccinated children from attending school until measles<br>outbreak is resolved.<\/li>\n\n\n\n<li>A preeclamptic client who delivered 24h ago remains in the labor and<br>delivery recovery room. She continues to receive magnesium sulfate at 2 grams per<br>hour. Her total input is limited to 125 ml per hour, and her urinary output for the<br>last hour was 850 ml. What intervention should the nurse implement?<br>(correct Answer- Continue with the plan of care for this client<\/li>\n\n\n\n<li>The nurse is planning care for a client who admits having suicidal thoughts.<br>Which client behavior indicates the highest risk for the client acting on these<br>suicidal thoughts?<br>(correct Answer- Begin to show signs of improvement in affect<\/li>\n\n\n\n<li>When assessing a multigravida the first postpartum day, the nurse finds a<br>moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths<br>above the umbilicus. What action should the nurse implement first?<br>(correct Answer- Check for a destined bladder<\/li>\n\n\n\n<li>A 12 year old client who had an appendectomy two days ago is receiving<br>0.9% normal saline at 50 ml\/hour. The client&#8217;s urine specific gravity is 1.035. What<br>action should the nurse implement?<br>(correct Answer- Encourage popsicles and fluids of choice<\/li>\n\n\n\n<li>An older male client arrives at the clinic complaining that his bladder always<br>feels full. He complains of weak urine flow, frequent dribbling after voiding, and<\/li>\n\n\n\n<li><\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Exit HESI (Actual hesi hints), EXIT HESI 2<br>what is considered a postpartum infection?<br>(correct ANS) &#8211; a fever on 2 consecutive days for the first 10 days postpartum not<br>including the first day<br>wound infections<br>mastitis<br>endometritis<br>UTIs<br>respiratory tract infections<br>what do you suspect in a child with an irregular pulse?<br>(correct ANS) &#8211; Kawasaki disease<br>what do you screen for on a newborn baby?<br>(correct ANS) &#8211; hypothyroidism<br>check T4 level (decreased)<br>what is an expected side effect of Solu-Medrol?<br>(correct ANS) &#8211; bleeding, bruising<br>what does Pilocarpine treat?<br>(correct ANS) &#8211; glaucoma<br>antidote is atropine sulfate<br>may get a dry mouth<br>TPN<br>(correct ANS) &#8211; central venous catheter<br>check for cloudiness<br>refrigerate- warm before administration<br>monitor electrolytes everyday<br>monitor for hyperglycemia and infection<br>change tubing with each new bag<br>nothing else goes through this line<br>what drug would you give is extravasation has occurred?<br>(correct ANS) &#8211; phentolamine (Regitine)- it&#8217;s a vasodilator and will increase blood<br>flow to the area to prevent necrosis<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">what diet would be chosen for a pt with CKD?<br>(correct ANS) &#8211; bread &amp; cream of wheat<br>pt receiving a blood transfusion develops fluid volume excess and dyspnea, what<br>do you do?<br>(correct ANS) &#8211; increase O2<br>what should you be monitoring in a client who has had a nephrectomy?<br>(correct ANS) &#8211; UOP<br>it is more important than drainage<br>what is important when caring for pt in skeletal traction?<br>(correct ANS) &#8211; pin care; sterile technique; remove crust; serous drainage is ok<br>how do you deal with a rude doctor that is avoided by the nurses?<br>(correct ANS) &#8211; staff meeting<br>what is confrontation?<br>(correct ANS) &#8211; calling attention to inconsistent behaviors<br>what is reflecting?<br>(correct ANS) &#8211; paraphrasing or repeating what client said<br>what client would most likely be experiencing delirium?<br>(correct ANS) &#8211; a client with constant pain or insomnia<br>what is the priority for a depressed client who has not slept?<br>(correct ANS) &#8211; sleep<br>a client who is bipolar is going home for the weekend to adjust for discharge. what<br>do you tell the family?<br>(correct ANS) &#8211; continue normal daily activities<br>if a client has a pulse with absent breath sounds on the left side what do you do?<br>(correct ANS) &#8211; prepare to reposition ETT<br>what do you monitor for in adrenal insufficiency (no steroids)?<br>(correct ANS) &#8211; shock<br>hyperkalemia<br>increase sodium in diet<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">if a client suddenly withdraws from steroids what do you do?<br>(correct ANS) &#8211; check VS<br>what do you teach a client taking prednisone?<br>(correct ANS) &#8211; monitor for hyperglycemia<br>take in morning<br>you are caring for a client with AIDS and you accidentally stick yourself with a<br>sterile needle. what do you do?<br>(correct ANS) &#8211; go get a new needle- no need to report<br>what do you teach a pt taking an antipyretic for and increased temp?<br>(correct ANS) &#8211; give with fluids because fever can cause dehydration<br>what is suspected if there is an increase in serosanguineous drainage?<br>(correct ANS) &#8211; dehiscence<br>what would you expect in a client with an epidural hematoma?<br>(correct ANS) &#8211; temporary loss of consciousness, followed by a lucid period, and<br>then gradually leading to coma<br>for maximum effectiveness, what should older clients use for dry skin?<br>(correct ANS) &#8211; petroleum based ointment<br>what are signs of pain in an infant?<br>(correct ANS) &#8211; grimacing<br>tachycardia<br>restlessness<br>irritability<br>difficulty feeding\/sleeping<br>increased RR<br>diaphoresis<br>decreased O2 levels<br>what is priority for a client with renal lithiasis?<br>(correct ANS) &#8211; address pain- these pts get pain meds immediately (don&#8217;t teach<br>important of straining urine- that&#8217;s RNs job)<br>what do you do for a pt on Amph B?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">(correct ANS) &#8211; monitor UOP- it&#8217;s nephrotoxic<br>what is the priority assessment in a client who has lost a tooth and has an eye<br>injury?<br>(correct ANS) &#8211; check pupils<br>where should the level of water be in the water seal chamber?<br>(correct ANS) &#8211; at 2cm<br>where should the level of water be in the suction control chamber?<br>(correct ANS) &#8211; at 20cm<br>how does a client present with DM2?<br>(correct ANS) &#8211; usually come back to doctor for wounds that won&#8217;t heal or vaginal<br>infections<br>don&#8217;t have enough insulin<br>insulin doesn&#8217;t work<br>a client in hypovolemic shock would present with what?<br>(correct ANS) &#8211; weak thready pulse<br>how would you teach someone to use an inhaler?<br>(correct ANS) &#8211; shake well for 5 seconds (if MDI)<br>exhale completely<br>press canister once and inhale deeply and slowly<br>hold breath for 10 seconds<br>wait 1 min between each puff<br>if using MDI- rinse mouth &amp; gargle after each use<br>nebulizers are better for peds and clients with severe asthma because it allows you<br>to breath normally<br>what is the appropriate action for a burn client in the emergent phase whose UOP<br>and BP are dropping?<br>(correct ANS) &#8211; immediately call the HCP<br>what do you monitor for in a client with HHS and DKA with insulin drip?<br>(correct ANS) &#8211; hypokalemia<br>U wave<br>what is priority discharge teaching for a client with HHS?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Exit HESI Test Bank (answered) spring 2022.<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>A nurse is providing information to a group of pregnant clients and their partners<br>about the psychosocial development of an infant. Using Erikson&#8217;s theory of<br>psychosocial development, what should the nurse tell the group about the<br>infants?<br>A. Rely on the fact that their needs will be met<br>B. Need to tolerate a great deal of frustration and discomfort to develop a<br>healthy personality<br>C. Must have needs ignored for short periods to develop a healthy<br>personality<br>D. Need to experience frustration, so it is best to allow an infant to cry for a<br>while before meeting his or her needs &#8211; A. Rely on the fact that their needs<br>will be met<\/li>\n\n\n\n<li>A nurse is weighing a breastfed 6-month-old infant who has been brought to the<br>pediatrician&#8217;s office for a scheduled visit. The infant&#8217;s weight at birth was 6 lb 8<br>oz. The nurse notes that the infant now weighs 13 lb. Which action should the<br>nurse take?<br>A. Tell the mother that the infant&#8217;s weight is increasing as expected<br>B. Tell the mother to decrease the daily number of feedings because the<br>weight gain is excessive<br>C. Tell the mother that semisolid foods should not be introduced until the<br>infant&#8217;s weight stabilizes<br>D. Tell the mother that the infant should be switched from breast milk to<br>formula because the weight gain is inadequate &#8211; A. Tell the mother that<br>the infant&#8217;s weight is increasing as expected<\/li>\n\n\n\n<li>A nurse performing a physical assessment of a 12-month-old infant notes that<br>the infant&#8217;s head circumference is the same as the chest circumference. Based<br>on this finding, what should the nurse do?<br>A. Suspect the presence of hydrocephalus<br>B. Suggest to the pediatrician that a skull x-ray be performed<br>C. Tell the mother that the infant is growing faster than expected<br>D. Document these measurements in the infant&#8217;s health-care record &#8211; D.<br>Document these measurements in the infant&#8217;s health-care record<\/li>\n\n\n\n<li>A new mother asks the nurse, &#8220;I was told that my infant received my antibodies<br>during pregnancy. Does that mean that my infant is protected against infections?&#8221;<br>Which statement should the nurse make in response to the mother?<br>A. &#8220;Yes, your infant is protected from all infections.&#8221;<br>B. &#8220;If you breastfeed, your infant is protected from infection.&#8221;<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">C. &#8220;The transfer of your antibodies protects your infant until the infant is 12<br>months old.&#8221;<br>D. &#8220;The immune system of an infant is immature, and the infant is at risk for<br>infection.&#8221; &#8211; D. &#8220;The immune system of an infant is immature, and the<br>infant is at risk for infection.&#8221;<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"5\">\n<li>A nurse is assessing the language development of a 9-month-old infant. Which<br>developmental milestone does the nurse expect to note in an infant of this age?<br>A. The infant babbles.<br>B. The infant says &#8220;Mama.&#8221;<br>C. The infant smiles and coos.<\/li>\n\n\n\n<li>D .The infant babbles single consonants. &#8211; B. The infant says &#8220;Mama.&#8221;<\/li>\n\n\n\n<li>The mother of a 9-month-old infant calls the nurse at the pediatrician&#8217;s office, tells<br>the nurse that her infant is teething, and asks what can be done to relieve the<br>infant&#8217;s discomfort. What should the nurse instruct the mother to do?<br>A. Schedule an appointment with a dentist for a dental evaluation<br>B. Rub the infant&#8217;s gums with baby aspirin that has been dissolved in water<br>C. Obtain an over-the-counter (OTC) topical medication for gum-pain relief<br>D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast<\/li>\n<\/ol>\n\n\n\n<ul class=\"wp-block-list\">\n<li>D. Give the infant cool liquids or a Popsicle and hard foods such as dry<br>toast<\/li>\n<\/ul>\n\n\n\n<ol class=\"wp-block-list\" start=\"5\">\n<li>A nurse is teaching the mother of an 11-month-old infant how to clean the infant&#8217;s<br>teeth. What should the nurse tell the mother to do?<br>A. Use water and a cotton swab and rub the teeth<br>B. Use diluted fluoride and rub the teeth with a soft washcloth<br>C. Use a small amount of toothpaste and a soft-bristle toothbrush<br>D. Dip the infant&#8217;s pacifier in maple syrup so that the infant will suck &#8211; A. Use<br>water and a cotton swab and rub the teeth<\/li>\n\n\n\n<li>A nurse provides information about feeding to the mother of a 6-month-old infant.<br>Which statement by the mother indicates an understanding of the information?<br>A. &#8220;I can mix the food in the my infant&#8217;s bottle if he won&#8217;t eat it.&#8221;<br>B. &#8220;Fluoride supplementation is not necessary until permanent teeth come<br>in.&#8221;<br>C. &#8220;Egg white should not be given to my infant because of the risk for an<br>allergy.&#8221;<br>10.D &#8220;Meats are really important for iron, and I should start feeding meats to my<br>infant right away.&#8221; &#8211; C. &#8220;Egg white should not be given to my infant because of<br>the risk for an allergy.&#8221;<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">11.A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2<br>oz about car safety. What should the nurse tell the mother?<br>A. To secure the infant in the middle of the back seat in a rear-facing infant<br>safety seat<br>B. To place the infant in a booster seat in the front seat of the car with the<br>shoulder and lap belts secured around the infant<br>C. That it is acceptable to place the infant in the front seat in a rear-facing<br>infant safety seat as long as the car has passenger-side air bags<br>D. That because of the infant&#8217;s weight it is acceptable to hold the infant as<br>long as the mother and infant are sitting in the middle of the back seat of<br>the car &#8211; A. To secure the infant in the middle of the back seat in a rearfacing infant safety seat<br>12.A nurse provides instructions to a mother about crib safety for her infant. Which<br>statement by the mother indicates a need for further instructions?<br>A. &#8220;I need to keep large toys out of the crib.&#8221;<br>B. &#8220;The drop side needs to be impossible for my infant to release.&#8221;<br>C. &#8220;Wood surfaces on the crib need to be free of splinters and cracks.&#8221;<br>D. &#8220;The distance between the slats needs to be no more than 4 inches wide<br>to prevent entrapment of my infant&#8217;s head or body.&#8221; &#8211; D. &#8220;The distance<br>between the slats needs to be no more than 4 inches wide to prevent<br>entrapment of my infant&#8217;s head or body.&#8221;<br>13.The mother of a 2-year-old tells the nurse that she is very concerned about her<br>child because he has developed &#8220;a will of his own&#8221; and &#8220;acts as if he can control<br>others.&#8221; The nurse provides information to the mother to alleviate her concern,<br>recalling that, according to Erikson, a toddler is confronting which developmental<br>task?<br>A. Initiative versus guilt<br>B. Trust versus mistrust<br>C. Industry versus inferiority<br>D. Autonomy versus doubt and shame &#8211; D. Autonomy versus doubt and<br>shame<br>14.A nurse is planning care for a hospitalized toddler. To best maintain the toddler&#8217;s<br>sense of control and security and ease feelings of helplessness and fear, which<br>action should the nurse take?<br>A. Spend as much time as possible with the toddler<br>B. Keep hospital routines as similar as possible to those at home<br>C. Allow the toddler to play with other children in the nursing unit playroom<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">D. Allow the toddler to select toys from the nursing unit playroom that can be<br>brought into the toddler&#8217;s hospital room &#8211; B. Keep hospital routines as<br>similar as possible to those at home<br>15.A nurse in a daycare setting is planning play activities for 2- and 3-year-old<br>children. Which toy is most appropriate for these activities?<br>A. Blocks and push-pull toys<br>B. Finger paints and card games<br>C. Simple board games and puzzles<br>D. Videos and cutting-and-pasting toys &#8211; A. Blocks and push-pull toys<br>16.A mother of twin toddlers tells the nurse that she is concerned because she<br>found her children involved in sex play and didn&#8217;t know what to do. What should<br>the nurse tell the mother?<br>A. To separate her children during playtime<br>B. That if the behavior continues, she will need to bring her children to a child<br>psychologist<br>C. That if she notes the behavior again she should casually tell her children<br>to dress and to direct them to another activity<br>D. To tell her children that what they are doing is bad and that they will be<br>punished if they are caught doing it again &#8211; C. That if she notes the<br>behavior again she should casually tell her children to dress and to direct<br>them to another activity<br>17.A nurse is assessing the motor development of a 24-month-old child. Which<br>activities would the nurse expect the mother to report that the child can perform?<br>Select all that apply.<br>A. Put on and tie his shoes<br>B. Align two or more blocks<br>C. Dress himself appropriately<br>D. Go to the bathroom without help<br>E. Turn the pages of a book one at a time &#8211; B. Align two or more blocks<br>F. Turn the pages of a book one at a time<br>18.A nurse is assessing language development in a toddler from a bilingual family.<br>What should the nurse expect about the child&#8217;s language development?<br>A. Is slower than expected<br>B. Is developing as expected<br>C. Is more advanced than expected<br>D. Will require assistance from a speech therapist &#8211; A. Is slower than<br>expected<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Comprehensive Exam133- Cyclobenzaprine (Flexeril) is prescribed to a client with multiple sclerosis for the treatment ofmuscle spasms. For which common side effect of this medication does the nurse monitor the client?A. DiarrheaB. Drowsiness CorrectC. Abdominal painD. Increased salivation134 &#8211; A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains ofchest pain. The [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-117270","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/117270","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=117270"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/117270\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=117270"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=117270"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=117270"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}