EXIT HESI PN END OF COURSE ANSWERS AND
QUESTIONS SET A+
✔✔The nurse should encourage a laboring client to begin pushing at which point?
A.When the cervix is completely effaced
B.When the client describes the need to have a bowel movement
C.When the cervix is completely dilated
D.When the anterior or posterior lip of the cervix is palpable - ✔✔C
Pushing begins with the second stage of labor, when the cervix is completely dilated at
10 cm (C). If pushing begins before the cervix is completely dilated (A, B, and D), the
cervix can become edematous and may never dilate completely, necessitating an
operative delivery. The most effective pushing occurs when the cervix is completely
dilated and the woman feels the urge to push (Ferguson's reflex).
✔✔The health care provider prescribes 1000 mL of a D5W solution to infuse over 8
hours for a client who has had a appendectomy. The IV tubing being using delivers 15
gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is
necessary, round to the nearest whole drop.)
A.15
B.32
C.64
D.50 - ✔✔B
Flow rate = 15 gtt/mL × (1000 mL/8 hr) × (1 hr/60 min) = 32 gtt/min
✔✔A 77-year-old female client states that she has never been so large around the waist
and that she has frequent periods of constipation. Colon disease has been ruled out
with a flexible sigmoidoscopy. Which information should the nurse provide to this client?
A.As women age, they often become rounder in the middle because they do not
exercise properly.
B.Further assessment is indicated because loss of abdominal muscle tone and
constipation do not occur with aging.
, C.With age, more fatty tissue develops in the abdomen and decreased intestinal
movement can cause constipation.
D.Because there is no evidence of a diseased colon, there is no need to worry about
abdominal size - ✔✔C
With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk
and waist. Slowing peristalsis also affects the emptying of the colon, resulting in
constipation (C). (A) is not the primary reason for the changes in body structure. (B) is
not indicated because loss of muscle tone and constipation are age-related changes.
(D) dismisses the client's concerns and does not help her understand the changes that
she is experiencing.
✔✔A male client with Parkinson's disease has been taking the antiparkinsonian agent
amantadine HCl (Symmetrel) for 4 months. He tells the home health nurse, "The
medicine doesn't seem to be working anymore." Which information should the nurse
provide to this client?
A.The dosage probably needs to be increased.
B.The medication needs to be changed immediately.
C.The medication needs to be taken more frequently.
D.The effects of this drug tend to decrease after 3 months. - ✔✔D
The beneficial effects of Symmetrel usually decrease in 3 to 6 months (D). It must be
discontinued gradually if necessary (B). Sometimes it is discontinued for a period of
time and then resumed at a higher dosage, and although (A) is partially correct, (D) is
more correct. Sometimes Symmetrel is given with other antiparkinsonian medications
as an adjunct, but (C) would have little effect.
✔✔A client with hepatic failure tells the nurse about recent use of acetaminophen
(Tylenol). How should the nurse respond to this client's statement?
A.Bleeding precautions should be implemented.
B.Tylenol is indicated for minor aches and pains.
C.Acetaminophen reduces inflammation.
D.The drug is hepatotoxic and contraindicated. - ✔✔D
Acetaminophen is hepatotoxic and can cause further complications for a client with
impaired liver function, so its use is contraindicated (D). Although bleeding (A) is a risk
in clients with liver disease caused by decreased production of clotting components, this
drug significantly increases this risk and is contraindicated. Although (B) is an indicated
use for this drug, it remains contraindicated in patients with hepatic failure. (C) is
inaccurate.
✔✔Which physiologic finding in an older adult contributes to an adverse drug reaction?
A.Reduced renal excretion
B.Reduced gastrointestinal motility
C.Increased hepatic metabolism
QUESTIONS SET A+
✔✔The nurse should encourage a laboring client to begin pushing at which point?
A.When the cervix is completely effaced
B.When the client describes the need to have a bowel movement
C.When the cervix is completely dilated
D.When the anterior or posterior lip of the cervix is palpable - ✔✔C
Pushing begins with the second stage of labor, when the cervix is completely dilated at
10 cm (C). If pushing begins before the cervix is completely dilated (A, B, and D), the
cervix can become edematous and may never dilate completely, necessitating an
operative delivery. The most effective pushing occurs when the cervix is completely
dilated and the woman feels the urge to push (Ferguson's reflex).
✔✔The health care provider prescribes 1000 mL of a D5W solution to infuse over 8
hours for a client who has had a appendectomy. The IV tubing being using delivers 15
gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is
necessary, round to the nearest whole drop.)
A.15
B.32
C.64
D.50 - ✔✔B
Flow rate = 15 gtt/mL × (1000 mL/8 hr) × (1 hr/60 min) = 32 gtt/min
✔✔A 77-year-old female client states that she has never been so large around the waist
and that she has frequent periods of constipation. Colon disease has been ruled out
with a flexible sigmoidoscopy. Which information should the nurse provide to this client?
A.As women age, they often become rounder in the middle because they do not
exercise properly.
B.Further assessment is indicated because loss of abdominal muscle tone and
constipation do not occur with aging.
, C.With age, more fatty tissue develops in the abdomen and decreased intestinal
movement can cause constipation.
D.Because there is no evidence of a diseased colon, there is no need to worry about
abdominal size - ✔✔C
With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk
and waist. Slowing peristalsis also affects the emptying of the colon, resulting in
constipation (C). (A) is not the primary reason for the changes in body structure. (B) is
not indicated because loss of muscle tone and constipation are age-related changes.
(D) dismisses the client's concerns and does not help her understand the changes that
she is experiencing.
✔✔A male client with Parkinson's disease has been taking the antiparkinsonian agent
amantadine HCl (Symmetrel) for 4 months. He tells the home health nurse, "The
medicine doesn't seem to be working anymore." Which information should the nurse
provide to this client?
A.The dosage probably needs to be increased.
B.The medication needs to be changed immediately.
C.The medication needs to be taken more frequently.
D.The effects of this drug tend to decrease after 3 months. - ✔✔D
The beneficial effects of Symmetrel usually decrease in 3 to 6 months (D). It must be
discontinued gradually if necessary (B). Sometimes it is discontinued for a period of
time and then resumed at a higher dosage, and although (A) is partially correct, (D) is
more correct. Sometimes Symmetrel is given with other antiparkinsonian medications
as an adjunct, but (C) would have little effect.
✔✔A client with hepatic failure tells the nurse about recent use of acetaminophen
(Tylenol). How should the nurse respond to this client's statement?
A.Bleeding precautions should be implemented.
B.Tylenol is indicated for minor aches and pains.
C.Acetaminophen reduces inflammation.
D.The drug is hepatotoxic and contraindicated. - ✔✔D
Acetaminophen is hepatotoxic and can cause further complications for a client with
impaired liver function, so its use is contraindicated (D). Although bleeding (A) is a risk
in clients with liver disease caused by decreased production of clotting components, this
drug significantly increases this risk and is contraindicated. Although (B) is an indicated
use for this drug, it remains contraindicated in patients with hepatic failure. (C) is
inaccurate.
✔✔Which physiologic finding in an older adult contributes to an adverse drug reaction?
A.Reduced renal excretion
B.Reduced gastrointestinal motility
C.Increased hepatic metabolism
