HESI EXIT RN V3 COMPREHENSIVE STUDY
GUIDE
◉ Which fluid will the nurse select to administer with the
prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
Answer: B
Rationale: Normal saline solution is the only solution that is
compatible with blood.
◉ When assisting a client from the bed to a chair, which procedure is
best for the nurse to follow?
A.
Place the chair parallel to the bed, with its back toward the head of
the bed and assist the client in moving to the chair.
,B.
With the nurse's feet spread apart and knees aligned with the
client's knees, stand and pivot the client into the chair.
C.
Assist the client to a standing position by gently lifting upward,
underneath the axillae.
D.
Stand beside the client, place the client's arms around the nurse's
neck, and gently move the client to the chair.
Answer: B
Rationale: Option B describes the correct positioning of the nurse
and affords the nurse a wide base of support while stabilizing the
client's knees when assisting to a standing position. The chair
should be placed at a 45-degree angle to the bed, with the back of
the chair toward the head of the bed. Clients should never be lifted
under the axillae; this could damage nerves and strain the nurse's
back. The client should be instructed to use the arms of the chair and
should never place his or her arms around the nurse's neck; this
places undue stress on the nurse's neck and back and increases the
risk for a fall.
◉ How many mL will the nurse document on the client's intake and
output record from the items listed? _____ mL
1200 mL water
4 ounce container of gelatin
,8 ounces of orange juice
355 mL can of soda1 cup of soup
Answer: Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 =
2155
◉ The nurse observes a UAP taking a client's blood pressure in the
lower extremity. Which observation of this procedure requires the
nurse to intervene with the UAP's approach?
A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower
leg.
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in
the client's arm.
Answer: B
Rationale: When obtaining the blood pressure in the lower
extremities, the popliteal pulse is the site for auscultation when the
blood pressure cuff is applied around the thigh. The nurse should
intervene with the UAP who has applied the cuff on the lower leg.
, Option A ensures an accurate assessment, and option C provides the
best access to the artery. Systolic pressure in the popliteal artery is
usually 10 to 40 mm Hg higher than in the brachial artery.
◉ During a clinic visit, the mother of a 7-year-old reports to the
nurse that her child is often awake until midnight playing and is then
very difficult to awaken in the morning for school. Which
assessment data should the nurse obtain in response to the mother's
concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is
experiencing
D.
Description of the family's home environment
Answer: D
Rationale: School-age children often resist bedtime. The nurse
should begin by assessing the environment of the home to
determine factors that may not be conducive to the establishment of
bedtime rituals that promote sleep. Option A often causes daytime
fatigue rather than resistance to going to sleep. Option B is unlikely
to provide useful data. The nurse cannot determine option C.
GUIDE
◉ Which fluid will the nurse select to administer with the
prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
Answer: B
Rationale: Normal saline solution is the only solution that is
compatible with blood.
◉ When assisting a client from the bed to a chair, which procedure is
best for the nurse to follow?
A.
Place the chair parallel to the bed, with its back toward the head of
the bed and assist the client in moving to the chair.
,B.
With the nurse's feet spread apart and knees aligned with the
client's knees, stand and pivot the client into the chair.
C.
Assist the client to a standing position by gently lifting upward,
underneath the axillae.
D.
Stand beside the client, place the client's arms around the nurse's
neck, and gently move the client to the chair.
Answer: B
Rationale: Option B describes the correct positioning of the nurse
and affords the nurse a wide base of support while stabilizing the
client's knees when assisting to a standing position. The chair
should be placed at a 45-degree angle to the bed, with the back of
the chair toward the head of the bed. Clients should never be lifted
under the axillae; this could damage nerves and strain the nurse's
back. The client should be instructed to use the arms of the chair and
should never place his or her arms around the nurse's neck; this
places undue stress on the nurse's neck and back and increases the
risk for a fall.
◉ How many mL will the nurse document on the client's intake and
output record from the items listed? _____ mL
1200 mL water
4 ounce container of gelatin
,8 ounces of orange juice
355 mL can of soda1 cup of soup
Answer: Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 =
2155
◉ The nurse observes a UAP taking a client's blood pressure in the
lower extremity. Which observation of this procedure requires the
nurse to intervene with the UAP's approach?
A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower
leg.
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in
the client's arm.
Answer: B
Rationale: When obtaining the blood pressure in the lower
extremities, the popliteal pulse is the site for auscultation when the
blood pressure cuff is applied around the thigh. The nurse should
intervene with the UAP who has applied the cuff on the lower leg.
, Option A ensures an accurate assessment, and option C provides the
best access to the artery. Systolic pressure in the popliteal artery is
usually 10 to 40 mm Hg higher than in the brachial artery.
◉ During a clinic visit, the mother of a 7-year-old reports to the
nurse that her child is often awake until midnight playing and is then
very difficult to awaken in the morning for school. Which
assessment data should the nurse obtain in response to the mother's
concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is
experiencing
D.
Description of the family's home environment
Answer: D
Rationale: School-age children often resist bedtime. The nurse
should begin by assessing the environment of the home to
determine factors that may not be conducive to the establishment of
bedtime rituals that promote sleep. Option A often causes daytime
fatigue rather than resistance to going to sleep. Option B is unlikely
to provide useful data. The nurse cannot determine option C.
