NCLEX HESI EXIT CRITICAL THINKING

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NCLEX HESI EXIT CRITICAL THINKING

EXAM QUESTIONS AND ANSWERS 2025

Which client would benefit from the application of warm moist heat? - correct answer- a client with low back pain

Direct application of warm moist heat would benefit a client with low back pain because the heat relaxes muscle spasms. Heat should not be applied to a client who has appendicitis because it can lead to rupture of the appendix and peritonitis. Ice is applied to recently sprained joints to help decrease edema.Applying heat to the area of a suspected malignancy can increase blood flow to the tumor and promote nourishment of the cancer cells.

A nurse is administering vitamin K to a neonate following birth.The medication comes in a concentration of 2 mg/ml, and the ordered dose is 0.5 mg to be given subcutaneously. How many milliliters would the nurse administer? Record your answer using two decimal places. - correct answer- 0.25

Use the following formula to calculate drug dosages:Dose on

hand/Quantity on hand = Dose desired/XPlug in the values and

the equation is as follows:2 mg/ml = 0.5 mg/XX = 0.25 ml.

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A child is to receive IV fluids at a rate of 95 mL/h. The tubing for the infusion delivers 10 drops/mL. At which rate should the nurse infuse the solution? - correct answer- 16 drops/min

To determine the number of drops per minute, multiply 95 ml/hour by 10 drops/mL (drop factor). This equals 950 mL/h.Dividing 950 mL/h by 60 min/h yields 15.8 drops/min.Therefore, 16 drops/min should be infused.

A 5-year-old child is brought to the emergency department after injuries sustained in a motor vehicle accident. The child is diagnosed with a cervical spinal cord injury. Which assessment data would the nurse consider as most significant when assessing for signs of cervical spinal cord swelling? - correct answer- changes in respiration

Impaired diaphragm function is common with cervical cord injuries in children and is potentially life threatening. It interferes with the ability to breathe, causing changes in respiration.

The healthcare provider prescribes meperidine hydrochloride 1.5 mg/kg intramuscularly to a school-age client. The pharmacy supplies meperidine hydrochloride injection as 50 mg/mL. The client weighs 25 kg. How many milliliters will the nurse administer? Record your answer using two decimal places. - correct answer- 0.75

1.5 mg/kg × 25 kg = 37.5 mg per dose 2 / 4

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37.5 mg / 50 mg x 1ml = 0.75 ml for injection

A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which indicator of early shock? - correct answer- heart rate above 100 beats/minute

In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation.The skin becomes cool and clammy.Urine output in early shock may be normal or slightly decreased.The client may experience increased restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock.

A client reports pain in the right heel and is requesting medication. The nurse assesses the client and administers an analgesic. The client experiences no pain relief and states that the heel pain is worse. What is an appropriate intervention by the nurse? - correct answer- Call the physician to report the finding.

The best response would be to notify the physician. The nurse cannot repeat the dose of analgesic without an order.Massaging the ankle and applying moist heat would be inappropriate for a number of reasons. The client could be developing a deep vein thrombosis, which may dislodge an embolus. Unrelieved pain indicates that an adverse event is developing, and the physician should be made aware of the situation. 3 / 4

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A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care? - correct answer- A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias.

A client with electrical burns based on energy and potential damage to the heart needs cardiac monitoring. Dextrose is not useful for fluid volume expansion and infection would occur much later. Urine output needs hourly monitoring based on myoglobin release.

During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse counts the apical pulse to be 157 beats per minute. Which is the most appropriate nursing action? - correct answer- Document this finding as on the high end of the normal range and plan to reassess.

Heart rates can be as fast as 180 bpm, but the normal range for a newborn heart rate is 110-160 bpm. Thus, the newborn's heart rate of 157 bpm is on the high end of the normal range, but still within the normal range. It would be appropriate to reassess the client's heart rate because newborn heart rates can fluctuate depending on the state of consciousness/wakefulness, hunger, temperature, and especially if the newborn is moving or startled. It would be inappropriate to call the pediatrician or to notify the charge

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