EXIT HESI PN REVIEW PAPER ANSWERS AND
QUESTIONS SET A+
✔✔Which assessment finding for a client with peritoneal dialysis requires immediate
intervention by the nurse?
A.The color of the dialysate outflow is opaque yellow.
B.The dialysate outflow is greater than the inflow.
C.The inflow dialysate feels warm to the touch.
D.The inflow dialysate contains potassium chloride. - ✔✔A
Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should
obtain a specimen for culture, assess the client, and notify the health care provider (A).
(B and C) are desired. (D) is commonly done to prevent hypokalemia.
✔✔The nurse is teaching a client newly diagnosed with diabetes mellitus about the
subcutaneous administration of Regular and NPH insulin. Which statement indicates
that the client needs further instruction?
A."I should balance my daily exercise with my dietary intake and insulin dosages."
B."When I give myself an injection, I should aspirate to make sure that I am not in a
blood vessel."
C."I should inject my insulin into a different site to reduce the development of scar
tissue."
D."I should remove the dose of clear insulin first and then the dose of cloudy insulin
from the vials." - ✔✔B
Aspiration (B) is not necessary when giving insulin because it could increase tissue
trauma and affect the absorption rate. (C) helps minimize tissue atrophy, which can
affect the absorption of the insulin. (A and D) are correct procedures. The client should
balance an active physical lifestyle with diet, insulin, and blood glucose monitoring to
ensure good serum glucose control. When mixing insulins in the same syringe, the clear
(Regular) insulin is withdrawn first to avoid contamination of the clear vial with cloudy
NPH insulin, which will alter the absorption rate of the remaining Regular insulin.
, ✔✔The nurse meets resistance while flushing a central venous catheter (CVC) at the
subclavian site. Which action should the nurse perform?
A.Examine for clamp closures.
B.Irrigate with a larger syringe.
C.Assess for signs of infection.
D.Flush the line with heparin. - ✔✔A
Thrombus formation, closed clamp, or crystallized medication can cause resistance
while flushing a central line, so the line should be assessed for closed clamps (A) first.
Irrigation with a larger syringe (B) will not alleviate the cause for the resistance and can
rupture the line. A central line infection (C) should not cause resistance while flushing
the line. The CVC should be flushed with normal saline (D) or a diluted solution of
heparin (10-100 U/mL) after (A) is completed, if necessary.
✔✔A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a
recent discharge. Which nursing intervention is most important in reducing the client's
stress associated with repeated hospitalization?
A.Allow the client to discuss the seriousness of the illness.
B.Ensure that the client is provided with information about medications.
C.Encourage as much independence in decision making as possible.
D.Include the client in planning the course of treatment. - ✔✔C
Hospitalization compromises an individual's sense of control and independence, which
contributes to stress, so allowing the client as much independence in decisions as
possible (C) helps reduce stress experienced with repeated hospitalization. (A, B, and
D) are important components in stress reduction, but the isolation and dependence
associated with hospitalization alter the client's sense of control and affect the client's
cognitive ability to understand (B) and participate (D) in the hospitalized plan of care.
✔✔According to Erikson, which client should the nurse identify as having difficulty
completing the developmental stage of older adults?
A.A 60-year-old man who tells the nurse that he is feeling fine and really does not need
any help from anyone
B.A 78-year-old widower who has come to the mental health clinic for counseling after
the recent death of his wife
C.An 81-year-old woman who states that she enjoys having her grandchildren visit but
is usually glad when they go home
D.A 75-year-old woman who wishes her friends were still alive so she could change
some of the choices she made over the years - ✔✔D
The older woman who wishes she could change the choices she has made in her
lifetime is expressing despair and is still searching for integrity (D). The nurse uses
Erikson stages of development over the life span to assess an older client's adjustment
to aging and plans teaching strategies to assist the clients attain integrity versus
despair. (A, B, and C) are normal developmental tasks of older adults.
QUESTIONS SET A+
✔✔Which assessment finding for a client with peritoneal dialysis requires immediate
intervention by the nurse?
A.The color of the dialysate outflow is opaque yellow.
B.The dialysate outflow is greater than the inflow.
C.The inflow dialysate feels warm to the touch.
D.The inflow dialysate contains potassium chloride. - ✔✔A
Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should
obtain a specimen for culture, assess the client, and notify the health care provider (A).
(B and C) are desired. (D) is commonly done to prevent hypokalemia.
✔✔The nurse is teaching a client newly diagnosed with diabetes mellitus about the
subcutaneous administration of Regular and NPH insulin. Which statement indicates
that the client needs further instruction?
A."I should balance my daily exercise with my dietary intake and insulin dosages."
B."When I give myself an injection, I should aspirate to make sure that I am not in a
blood vessel."
C."I should inject my insulin into a different site to reduce the development of scar
tissue."
D."I should remove the dose of clear insulin first and then the dose of cloudy insulin
from the vials." - ✔✔B
Aspiration (B) is not necessary when giving insulin because it could increase tissue
trauma and affect the absorption rate. (C) helps minimize tissue atrophy, which can
affect the absorption of the insulin. (A and D) are correct procedures. The client should
balance an active physical lifestyle with diet, insulin, and blood glucose monitoring to
ensure good serum glucose control. When mixing insulins in the same syringe, the clear
(Regular) insulin is withdrawn first to avoid contamination of the clear vial with cloudy
NPH insulin, which will alter the absorption rate of the remaining Regular insulin.
, ✔✔The nurse meets resistance while flushing a central venous catheter (CVC) at the
subclavian site. Which action should the nurse perform?
A.Examine for clamp closures.
B.Irrigate with a larger syringe.
C.Assess for signs of infection.
D.Flush the line with heparin. - ✔✔A
Thrombus formation, closed clamp, or crystallized medication can cause resistance
while flushing a central line, so the line should be assessed for closed clamps (A) first.
Irrigation with a larger syringe (B) will not alleviate the cause for the resistance and can
rupture the line. A central line infection (C) should not cause resistance while flushing
the line. The CVC should be flushed with normal saline (D) or a diluted solution of
heparin (10-100 U/mL) after (A) is completed, if necessary.
✔✔A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a
recent discharge. Which nursing intervention is most important in reducing the client's
stress associated with repeated hospitalization?
A.Allow the client to discuss the seriousness of the illness.
B.Ensure that the client is provided with information about medications.
C.Encourage as much independence in decision making as possible.
D.Include the client in planning the course of treatment. - ✔✔C
Hospitalization compromises an individual's sense of control and independence, which
contributes to stress, so allowing the client as much independence in decisions as
possible (C) helps reduce stress experienced with repeated hospitalization. (A, B, and
D) are important components in stress reduction, but the isolation and dependence
associated with hospitalization alter the client's sense of control and affect the client's
cognitive ability to understand (B) and participate (D) in the hospitalized plan of care.
✔✔According to Erikson, which client should the nurse identify as having difficulty
completing the developmental stage of older adults?
A.A 60-year-old man who tells the nurse that he is feeling fine and really does not need
any help from anyone
B.A 78-year-old widower who has come to the mental health clinic for counseling after
the recent death of his wife
C.An 81-year-old woman who states that she enjoys having her grandchildren visit but
is usually glad when they go home
D.A 75-year-old woman who wishes her friends were still alive so she could change
some of the choices she made over the years - ✔✔D
The older woman who wishes she could change the choices she has made in her
lifetime is expressing despair and is still searching for integrity (D). The nurse uses
Erikson stages of development over the life span to assess an older client's adjustment
to aging and plans teaching strategies to assist the clients attain integrity versus
despair. (A, B, and C) are normal developmental tasks of older adults.
