HESI RN EXIT Comprehensive V3 Exam
1. A 38-year-old female client is admitted to the mental health unit after
a recent manic episode of spending large amounts of money on new
furniture,making excessive long-distance phone calls, and not sleeping
for three days.During the admission process, the client is wearing a green
bathing suit. Whatintervention should the nurse implement
Answer: Assess the client's needs for food, liquids, and rest.
2. During a group therapy session, a client with hypomania threatens to
strikeanother client. What intervention is best for the nurse to
implement
Answer: Firmly inform the client that acting out anger is not acceptable.
3. A client who is a laboratory technician and has a history of allergic
rhinitis,asthma, and multiple food allergies is scheduled for surgery.
Which action should the nurse implement
Answer: Document a possible Type I latex allergy.
,4. In reviewing the medical record, the nurse notes that a client's last eye
examination revealed an IOP of 28 mmHg. What information should the
nurseask the client
Answer: Use of prescribed eye drops since last exam by ophthalmologist.
5. Which action should the nurse implement to assess for JVD in a client
withHF
Answer: Observe the vertical distention of the veins as the client is
gradually elevatedto an upright position.
6. The nurse identifies a client's laboratory results and identifies an
elevated serum ammonia level. Which pathophysiological process
contributes to this finding
Answer: Failure of the liver to convert ammonia absorbed from the bowel
to urea.
7. A client with GERD is unconscious and unresponsive to stimuli. The
nurse places the client in a side-lying position. The nurse should monitor
, for the riskof which complication
Answer: Aspiration pneumonia.
8. A client returns to the unit after abdominal Nissen fundoplication for
treat-ment of GERD. After 4 hours, the nurse determines the client has no
drainagefrom the NGT and has absent bowel sounds. What action should
the nurse implement
Answer: Irrigate the NGT with normal saline.
9. A male client who is admitted with a bleeding peptic ulcer develops
sudden,severe upper abdominal pain. The client becomes diaphoretic and
draws
his knees over his abdomen. Which finding should the nurse report to the
healthcare provider
Answer: A rigid, boardlike abdomen.
10. A client returns to the postoperative unit after a gastroduodenostomy
(Billroth I) for treatment of a perforated ulcer. The healthcare provider's
pre- scriptions include morphine with a patient-controlled analgesia
(PCA), na- sogastric tube (NGT) to low intermittent nasogastric suction,
1. A 38-year-old female client is admitted to the mental health unit after
a recent manic episode of spending large amounts of money on new
furniture,making excessive long-distance phone calls, and not sleeping
for three days.During the admission process, the client is wearing a green
bathing suit. Whatintervention should the nurse implement
Answer: Assess the client's needs for food, liquids, and rest.
2. During a group therapy session, a client with hypomania threatens to
strikeanother client. What intervention is best for the nurse to
implement
Answer: Firmly inform the client that acting out anger is not acceptable.
3. A client who is a laboratory technician and has a history of allergic
rhinitis,asthma, and multiple food allergies is scheduled for surgery.
Which action should the nurse implement
Answer: Document a possible Type I latex allergy.
,4. In reviewing the medical record, the nurse notes that a client's last eye
examination revealed an IOP of 28 mmHg. What information should the
nurseask the client
Answer: Use of prescribed eye drops since last exam by ophthalmologist.
5. Which action should the nurse implement to assess for JVD in a client
withHF
Answer: Observe the vertical distention of the veins as the client is
gradually elevatedto an upright position.
6. The nurse identifies a client's laboratory results and identifies an
elevated serum ammonia level. Which pathophysiological process
contributes to this finding
Answer: Failure of the liver to convert ammonia absorbed from the bowel
to urea.
7. A client with GERD is unconscious and unresponsive to stimuli. The
nurse places the client in a side-lying position. The nurse should monitor
, for the riskof which complication
Answer: Aspiration pneumonia.
8. A client returns to the unit after abdominal Nissen fundoplication for
treat-ment of GERD. After 4 hours, the nurse determines the client has no
drainagefrom the NGT and has absent bowel sounds. What action should
the nurse implement
Answer: Irrigate the NGT with normal saline.
9. A male client who is admitted with a bleeding peptic ulcer develops
sudden,severe upper abdominal pain. The client becomes diaphoretic and
draws
his knees over his abdomen. Which finding should the nurse report to the
healthcare provider
Answer: A rigid, boardlike abdomen.
10. A client returns to the postoperative unit after a gastroduodenostomy
(Billroth I) for treatment of a perforated ulcer. The healthcare provider's
pre- scriptions include morphine with a patient-controlled analgesia
(PCA), na- sogastric tube (NGT) to low intermittent nasogastric suction,
