HESI RN EXIT FINAL PAPER UPDATED
QUESTIONS VERIFIED COMPLETE
ANSWERS 100 PERCENT CORRECT
◉ A 20-year-old female client with a noticeable body odor has
refused to shower for the last 3 days. She states, "I have been told
that it is harmful to bathe during my period." Which action should
the nurse take first?
A.
Accept and document the client's wish to refrain from bathing.
B.
Offer to give the client a bed bath, avoiding the perineal area.
C.
Obtain written brochures about menstruation to give to the client.
D.
Teach the importance of personal hygiene during menstruation with
the client.
Answer: D
Rationale: Because a shower is most beneficial for the client in terms
of hygiene, the client should receive teaching first, respecting any
personal beliefs such as cultural or spiritual values. After client
teaching, the client may still choose option A or B. Brochures
reinforce the teaching.
,◉ The spouse is at the bedside of the client who just died. The
hospice nurse states to the spouse, "I know your children want to
come over and say goodbye before we call the funeral home. Just let
me know when you are ready for me to prepare the body." What
steps will the nurse include in the postmortem care? (Select all that
apply.)
A.
Remove the existing Foley catheter.
B.
Wash the genitalia only.
C.
Close the client's eyes.
D.
Remove soiled padding under the client.
E.
Place a dressing over the abdominal scar.
Answer: A, C, D
Rationale: Postmortem care includes making the client ready for the
family to view prior to the client's transfer to the mortuary. The
nurse need to make sure the client's body is completely washed, and
all dressings and all tubes, i.e. Foley, NG, IV, are removed. As the
client may excrete contents from the bowel and the bladder during
the dying process, remove all soiled pads and bedding from under
,the client and replace with fresh items. Make sure the client's eyes
are closed.
◉ A hospitalized client has had difficulty falling asleep for two
nights, and is becoming irritable and restless. Which action by the
nurse is best?
A.
Determine the client's usual bedtime routine and include these
rituals in the plan of care as safety allows.
B.
Instruct the UAP not to wake the client under any circumstances
during the night.
C.
Place a "Do Not Disturb" sign on the door and change assessments
from every 4 to 8 hours.
D.
Encourage the client to avoid pain medication during the day, which
might increase daytime napping.
Answer: A
Rationale: Including habitual rituals that do not interfere with the
client's care or safety may allow the client to go to sleep faster and
increase the quality of care. Options B, C, and D decrease the client's
standard of care and compromise safety.
, ◉ Which instruction is most important for the nurse to include
when teaching a client with limited mobility strategies to prevent
venous thrombosis?
A.
Perform cough and deep breathing exercises hourly.
B.
Turn from side to side in bed at least every 2 hours.
C.
Dorsiflex and plantarflex the feet 10 times each hour.
D.
Drink approximately 4 ounces of water every hour.
Answer: C
Rationale: To reduce the risk of venous thrombosis, the nurse should
instruct the client in measures that promote venous return, such as
dorsiflexion and plantar flexion. Options A, B, and D are helpful to
prevent other complications of immobility but are less effective in
preventing venous thrombus formation than option C.
◉ For the client with a sodium level of 128 mEq/L, which meal
selections should the nurse suggest to the client? (Select all that
apply.)
A.
Bacon, egg, and cheese biscuit
B.
QUESTIONS VERIFIED COMPLETE
ANSWERS 100 PERCENT CORRECT
◉ A 20-year-old female client with a noticeable body odor has
refused to shower for the last 3 days. She states, "I have been told
that it is harmful to bathe during my period." Which action should
the nurse take first?
A.
Accept and document the client's wish to refrain from bathing.
B.
Offer to give the client a bed bath, avoiding the perineal area.
C.
Obtain written brochures about menstruation to give to the client.
D.
Teach the importance of personal hygiene during menstruation with
the client.
Answer: D
Rationale: Because a shower is most beneficial for the client in terms
of hygiene, the client should receive teaching first, respecting any
personal beliefs such as cultural or spiritual values. After client
teaching, the client may still choose option A or B. Brochures
reinforce the teaching.
,◉ The spouse is at the bedside of the client who just died. The
hospice nurse states to the spouse, "I know your children want to
come over and say goodbye before we call the funeral home. Just let
me know when you are ready for me to prepare the body." What
steps will the nurse include in the postmortem care? (Select all that
apply.)
A.
Remove the existing Foley catheter.
B.
Wash the genitalia only.
C.
Close the client's eyes.
D.
Remove soiled padding under the client.
E.
Place a dressing over the abdominal scar.
Answer: A, C, D
Rationale: Postmortem care includes making the client ready for the
family to view prior to the client's transfer to the mortuary. The
nurse need to make sure the client's body is completely washed, and
all dressings and all tubes, i.e. Foley, NG, IV, are removed. As the
client may excrete contents from the bowel and the bladder during
the dying process, remove all soiled pads and bedding from under
,the client and replace with fresh items. Make sure the client's eyes
are closed.
◉ A hospitalized client has had difficulty falling asleep for two
nights, and is becoming irritable and restless. Which action by the
nurse is best?
A.
Determine the client's usual bedtime routine and include these
rituals in the plan of care as safety allows.
B.
Instruct the UAP not to wake the client under any circumstances
during the night.
C.
Place a "Do Not Disturb" sign on the door and change assessments
from every 4 to 8 hours.
D.
Encourage the client to avoid pain medication during the day, which
might increase daytime napping.
Answer: A
Rationale: Including habitual rituals that do not interfere with the
client's care or safety may allow the client to go to sleep faster and
increase the quality of care. Options B, C, and D decrease the client's
standard of care and compromise safety.
, ◉ Which instruction is most important for the nurse to include
when teaching a client with limited mobility strategies to prevent
venous thrombosis?
A.
Perform cough and deep breathing exercises hourly.
B.
Turn from side to side in bed at least every 2 hours.
C.
Dorsiflex and plantarflex the feet 10 times each hour.
D.
Drink approximately 4 ounces of water every hour.
Answer: C
Rationale: To reduce the risk of venous thrombosis, the nurse should
instruct the client in measures that promote venous return, such as
dorsiflexion and plantar flexion. Options A, B, and D are helpful to
prevent other complications of immobility but are less effective in
preventing venous thrombus formation than option C.
◉ For the client with a sodium level of 128 mEq/L, which meal
selections should the nurse suggest to the client? (Select all that
apply.)
A.
Bacon, egg, and cheese biscuit
B.
