HESI 799 RN EXIT UPDATED CORE EXAM MANUAL
QUESTIONS AND ANSWERS MARKED A+
✔✔While monitoring a client during a seizure, which interventions should the nurse
implement? (Select all that apply)
a. Move obstacle away from client
b. Monitor physical movements
c. Insert an oral padded tongue blade
d. Observe for a patent airway
e. Record the duration of the seizure
f. Restrain extremity to avoid seizures - ✔✔a. Move obstacle away from client
b. Monitor physical movements
d. Observe for a patent airway
e. Record the duration of the seizure
Rationale: Moving this away from the client helps prevent to unnecessary injurie.
Observing for the pt airway alert the nurse to provide airway assistance as soon as the
seizure stop D and E provide the healthcare provider with an accurate description of the
seizure activities. C inserting something on the mouth can obstruct may cause further
airway obstruction and is contraindicated even if the client is biting the tongue. F may
cause further injury and is contraindicated.
✔✔A male client with a long history of alcoholism is admitted because of mild confusion
and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking
cigarettes one month ago after his brother died of lung cancer. Which intervention is
most important for the nurses to include in the client's plan of care?
a. Determine client's level current blood alcohol level.
b. Observe for changes in level of consciousness.
c. Involve the client's family in healthcare decisions.
d. Provide grief counseling for client and his family. - ✔✔b. Observe for changes in level
of consciousness.
Rationale: Based on the client's history of drinking, he may be exhibiting sign of hepatic
involvement and encephalopathy. Changes in the client's level of consciousness should
be monitored to determine if he able to maintain consciousness, so neurological
assessment has the highest priority.
✔✔An older adult female admitted to the intensive care unit (ICU) with a possible stroke
is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of
12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31.
PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding,
which action is required?
a. Report the results to the healthcare provider.
, b. Increase ventilator rate.
c. Administer a dose of sodium carbonate.
d. Decrease the flow rate of oxygen. - ✔✔Increase ventilator rate.
Rationale: This client is experience respiratory acidosis. Increasing the ventilator rate
depletes CO2 a, which returns the PH toward normal. Report findings is important but
only after increasing ventilator rate
✔✔The mother of the 12- month-old with cystic fibrosis reports that her child is
experiencing increasing congestion despite the use of chest physical therapy (CPT)
twice a day, and has also experiences a loss of appetite. What instruction should the
nurse provide?
a. Perform CPT after meals to increase appetite and improve food intake.
b. CPT should be performed more frequently, but at least an hour before meals.
c. Stop using CPT during the daytime until the child has regained an appetite.
d. Perform CPT only in the morning, but increase frequency when appetite improves. -
✔✔CPT should be performed more frequently, but at least an hour before meals.
Rationale: CPT with inhalation therapy should be performed several times a day to
loosen the secretions and move them from the peripheral airway into the central airways
where they can be expectorated. CPT should be done at least one hour before meals or
two hours after meals.
✔✔The nurse is evaluating the diet teaching of a client with hypertension. What dinner
selection indicates that the client understands the dietary recommendation for
hypertension?
a. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie.
b. Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie.
c. Grilled steak, baked potato with sour cream, green beans, coffee and raisin cream
pie.
d. Beed stir fry, fried rice, egg drop soup, diet coke and pumpkin pie. - ✔✔Baked pork
chop, applesauce, corn on the cob, 2% milk, and key-lime pie
Rationale: B is limited in sodium, is high in fiber, and no additional fat is added through
cooking, so it is the best choice for an antihypertensive meal. A high in sodium and
cholesterol, which should be avoid. C is high in fat and caffeine which can elevate the
BP D is high in sodium and cholesterol and includes caffeine.
✔✔A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic
episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units
subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are
prescribed. What action should the nurse include in this client's plan of care?
QUESTIONS AND ANSWERS MARKED A+
✔✔While monitoring a client during a seizure, which interventions should the nurse
implement? (Select all that apply)
a. Move obstacle away from client
b. Monitor physical movements
c. Insert an oral padded tongue blade
d. Observe for a patent airway
e. Record the duration of the seizure
f. Restrain extremity to avoid seizures - ✔✔a. Move obstacle away from client
b. Monitor physical movements
d. Observe for a patent airway
e. Record the duration of the seizure
Rationale: Moving this away from the client helps prevent to unnecessary injurie.
Observing for the pt airway alert the nurse to provide airway assistance as soon as the
seizure stop D and E provide the healthcare provider with an accurate description of the
seizure activities. C inserting something on the mouth can obstruct may cause further
airway obstruction and is contraindicated even if the client is biting the tongue. F may
cause further injury and is contraindicated.
✔✔A male client with a long history of alcoholism is admitted because of mild confusion
and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking
cigarettes one month ago after his brother died of lung cancer. Which intervention is
most important for the nurses to include in the client's plan of care?
a. Determine client's level current blood alcohol level.
b. Observe for changes in level of consciousness.
c. Involve the client's family in healthcare decisions.
d. Provide grief counseling for client and his family. - ✔✔b. Observe for changes in level
of consciousness.
Rationale: Based on the client's history of drinking, he may be exhibiting sign of hepatic
involvement and encephalopathy. Changes in the client's level of consciousness should
be monitored to determine if he able to maintain consciousness, so neurological
assessment has the highest priority.
✔✔An older adult female admitted to the intensive care unit (ICU) with a possible stroke
is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of
12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31.
PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding,
which action is required?
a. Report the results to the healthcare provider.
, b. Increase ventilator rate.
c. Administer a dose of sodium carbonate.
d. Decrease the flow rate of oxygen. - ✔✔Increase ventilator rate.
Rationale: This client is experience respiratory acidosis. Increasing the ventilator rate
depletes CO2 a, which returns the PH toward normal. Report findings is important but
only after increasing ventilator rate
✔✔The mother of the 12- month-old with cystic fibrosis reports that her child is
experiencing increasing congestion despite the use of chest physical therapy (CPT)
twice a day, and has also experiences a loss of appetite. What instruction should the
nurse provide?
a. Perform CPT after meals to increase appetite and improve food intake.
b. CPT should be performed more frequently, but at least an hour before meals.
c. Stop using CPT during the daytime until the child has regained an appetite.
d. Perform CPT only in the morning, but increase frequency when appetite improves. -
✔✔CPT should be performed more frequently, but at least an hour before meals.
Rationale: CPT with inhalation therapy should be performed several times a day to
loosen the secretions and move them from the peripheral airway into the central airways
where they can be expectorated. CPT should be done at least one hour before meals or
two hours after meals.
✔✔The nurse is evaluating the diet teaching of a client with hypertension. What dinner
selection indicates that the client understands the dietary recommendation for
hypertension?
a. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie.
b. Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie.
c. Grilled steak, baked potato with sour cream, green beans, coffee and raisin cream
pie.
d. Beed stir fry, fried rice, egg drop soup, diet coke and pumpkin pie. - ✔✔Baked pork
chop, applesauce, corn on the cob, 2% milk, and key-lime pie
Rationale: B is limited in sodium, is high in fiber, and no additional fat is added through
cooking, so it is the best choice for an antihypertensive meal. A high in sodium and
cholesterol, which should be avoid. C is high in fat and caffeine which can elevate the
BP D is high in sodium and cholesterol and includes caffeine.
✔✔A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic
episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units
subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are
prescribed. What action should the nurse include in this client's plan of care?
