HESI Comprehensive PN EXIT Exam

HESI Comprehensive PN EXIT Exam The nurse is planning care for the a client who has fourth degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priority? A. Administer Prescribed stool softner B. Administer prescribed PRN sleep medications. C. Encourage breastfeeding to promote uterine involution D. Encourage use of prescribed analgesic perineal sprays. A. Administer Prescribed stool softner The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area. A. Duodenum B. Gastric Pylorus C. Liver D. Spleen C. Liver A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report? A. Decreased sexual libido B. Amenorrhea C. Quickening D. Nocturia B. Amenorrhea A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make? A. Ask for a description of what happened during the night B. Tell the daughter to talk to the unit's nurse manager C. Reassure the daughter that the mother will get better care. D. Explain that all the staff are doing the best they can. A. Ask for a description of what happened during the night A hosptitalized toddler who is recovering from a sickle cell crisis holds a toy and say's "mine". According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage? A. Autonomy vs. Shame and doubt. B. Industry vs. Inferiority C. intiative vs. Guilt D. Trust vs. Mistrust A. Autonomy vs. Shame and doubt. Which action should the nurse implement in caring for a client following an electroencephalogram (EEG)? A. Monitor the client's vital signs q4h B. Assess for sensation in the client's lower extremities C. Instruct the client to maintain bed rest for eight hours D. Wash any paste from the client's hair and scalp D. Wash any paste from the client's hair and scalp The nurse is caring for a 75- year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpfull in preventing further development of the decubitus? A. Encourage the client to eat foods high in protein B. Assess the client with daily range of motion exercises C. Teach the family how to perform sterile wound care D. Ensure the IV fluids are administered as prescribed A. Encourage the client to eat foods high in protein What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space? A. Filtration B. Diffusion C. Osmosis D. Active transport C. Osmosis The nurse is taking blood presure of a client admitted with a possible myocardial infarction. When taking the client's BP at the brachial artery, the nurse should place the client's arm in which position? A. Slightly above the level of the heart B. At the level of the heart C. At the level of comfort for the client D. Below the level of the heart B. At the level of the heart What are the final parameters that produce blood pressure? (select all that apply) A. Heart rate B. Stroke volume C. Peripheral resistance D. Neuroendocring hormones E. Muscle tone A. Heart rate B. Stroke volume C. Peripheral resistance A client begins an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant? A. Appetite B. Mood C. Withdrawl D. Energy level B. Mood Based on the documentation in the medical record, which action should the nurse implement next? A. Give the rubella vaccine subcutaneously B. Observe the mother breastfeeding her infant C. Call the nursery for the infant's blodd type result D. Administer Vicodin one tablet for pain A. Give the rubella vaccine subcutaneously Upgrade to remove ads Only $3.99/month A client is admitted to the hosptial with a diagnosis of Pneumonia. Which intervetion should the nurse implement to prevent complications associated with Pneumonia? A. Enourage mobilization and ambulation B. Encourage energy conservation with complete bed rest C. Provide humidified oxygen per nasal cannula D. Restrict PO and intravenous fluids A. Enourage mobilization and ambulation The practical nurse is preparing to administer a prescription for cefazolin (kefzol) 600 mg IM every 6 hours. The available vial is labeled, "Cefazolin (Kefzol) 1 gram and the instrutions for reconsittution, "For IM use add 2ml sterile water for injection. Total volume after reconstruction = 2.5 ml. "when reconstituded, how many milligrams are in each mil of solutions (Enter numeric value only) 15 Which nursing activity is within the scope of practice for the practical nurse? A. Complete an admission assessment in the normal newborn nursery. B. Discontinue a central venous catheter that has become dislodged C. Observe a client rotate the subcutaneous site for an insulin pump D. Monitor a continous narcotic epidural for a postoperative client C. Observe a client rotate the subcutaneous site for an insulin pump After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the unlicensed assistive personnel? A. Identify the need for additional supplies to provide an extra dressing change B. Provide perianal care and collect clean linens for the dressing change C. Document the diarrhea that necessitates an additional dressing change D. Position the client for access to the decubiti sties and remove dressings B. Provide perianal care and collect clean linens for the dressing change The nurse is planning to evaluate the effectiveness of several drugs administered by different routes. Arrage the routes of administration in the order from fastest to slowest rate of absorption. Subcutaenous Intravenous Intramuscular Sublingual Oral Intravenous, sublingual, intramuscular, subcutaneous, oral. A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-house post dilation and curettage (D&C) the nurse assess the vital signs and vaginal bleeding. The client begins to cry softly. How should the nurse intervene? A. Offer to call the social worker to discuss the possiblity of abortion B. Reassure the client that the infertility specialist can help C. Express sorrow for the client's grief and offer to sit with her D. Chart the vital signs and amount of vaginal bleeding C. Express sorrow for the client's grief and offer to sit with her A terminally ill male client and his family are requesting hospice care after discharge from the hosptial and ask the nurse to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care? A. Enhance symptom management to improve end of life quality B. facilitates assisted suicide with the client's consent C. Offers ways to postpone the death experience at home D. Provide training for family members to care for the client. A. Enhance symptom management to improve end of life quality The nurse observes a wife shaving her husband's beard with a safety razor by holding the skin taut and shaving in the direction of the hair growth . What action should the nurse take? A. Advise the wife to shave against the hair growth B. Teach the wife to keep the skin loose to avoid cuts C. Encourage the wife to continue shaving her husband D. Demonstrate the correct procedure to the wife C. Encourage the wife to continue shaving her husband To assess pedal pulse what arterial sites should the nurse palpate? (select all that apply) A. Posterior tibialis artery B. Politeal artery C. External femoral artery D. Dorsalis pedis artery E Radial artery A. Posterior tibialis artery, D. Dorsalis pedis artery The nurse is admitting a client who is diagnosed with Angina Pectoris. Which precipitating factor in this client's history is likely to be related to the anginal pain? A. Smokes one pack of cigarettes daily B. Drinks two beers daily C. Works in a job that requires exposure to the sun D. Eats while lying in bed A. Smokes one pack of cigarettes daily Upgrade to remove ads Only $3.99/month The nurse is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catherterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's PO intake is 600 mL, and fifteen minutes ago, the client voided 90 mL. What action should the nurse take? A. Stand the client to void and run tap water within hearing distance before catheterizing the client. B. Straight catheterize and if the residual uring volume is greater than 100 mL, clamp catheter C. Catheterize q2H and place in an indwelling catheter at the end of the prescribed 24hr period. D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon. D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon. A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the nurse recognize as Cushionoid side effects? A. Moon face, Slow wound healing, muscle wasting sodium and water retention B. Tachycardia hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor C. Bradycardia, weight gain, cold intolerance, myxedema facies and periobarbital edema D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension A. Moon face, Slow wound healing, muscle wasting sodium and water retention The cervix is the opening into the uterine cavity. What is its function in reproduction? A. Accepts and interprets signals of sexual stimuli B. Secretes mucus to facilitate sperm transport C. Serves as the site for union of ovum ans sperm D. Receives the penis during intercourse B. Secretes mucus to facilitate sperm transport The nurse is working in a community health setting and assisting the charge nurse in performing health screenings. Which individual is at highest risk for contracting an HIV infection? A. 17-year-old who is sexually active simultaneously with numerous partners B. 34-year old homosexual who is in a monogamous relationship C. 30-year-old cocaine user who inhales and smokes drugs D. 45-year-old who has received two blood transfusions in the past 6 months A. 17-year-old who is sexually active simultaneously with numerous partners The nurse is administering amiodarone (Cordarone) to a client who has been admitted with Atrial Fibrillation (AFIB). What therapeutic response should the nurse anticipate? A. Conversion of irregular heart rate to regular heart rhythm B. Pulse oximetry readings within normal range during activity C. Peripheral pulse points with adequate capillary refill D. Increase excercise tolerance without shortness of breath A. Conversion of irregular heart rate to regular heart rhythm An elderly male client is planning to vacation with a group of senior citizens. He is concerned about developing constipation during the airplane flight. He share this concern with the nurse at the retirement home. Which recommendation is best for the nurse to provide? A. Use an over the counter stool softener when needed B. Eat a high protein diet C Increase the fluid intake in your diet D. Decrease the fat content in your diet C. Increase the fluid intake in your diet The nurse is assessing a client with dark skin who is in Respiratory Distress. Which client response should the nurse evaluate to determine cyanosis in this particular client? A. Abnormal skin color changes in a client with dark skin cannot be determined B. Blanching the soles of the feet in a client with dark skin reveals cyanosis C. The lips and mucus membranes of a client with dark skin are dusky in color D. Cyanosis in a client with dark skin is seen in the sclera C. The lips and mucus membranes of a client with dark skin are dusky in color When inserting an indwelling urinary catheter (Foley) in a female client, the nurse observes uring flow into the tubing. What action is taken next? A. Document the color and clarity of the urine B. Insert the catheter an additional inch C. Ask the client to breathe deeply and slowly exhale D. Inflate the balloon with 5mL of sterile water B. Insert the catheter an additional inch A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a lumber Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality? A. Mild electrical stimulus on the skin surface closes the gates of nerve conduction for sever pain B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus C. An infusion of medication in the spinal canal will block pain perception D. The discharge of electricity will distract the client's focus on the pain B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus Based on the Nursing diagnosis of "Potential for infection related to second and third degree burns," which intervention has the highest priority? A. Application of topical antibacterial cream B. Use of careful hand washing technique C. Administration of plasma expanders D. Limiting visitors to the burned client. B. Use of careful hand washing technique Upgrade to remove ads Only $3.99/month The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder, which assessment finding is the most significant indicator of possible child abuse? A. The child looks at the floore when answering the nurse's questions B. The mother's version of the injury is different from the child's version C. The child has several abrasions on the chest and legs D. The mother refuses to answer questions about family history D. The mother refuses to answer questions about family history A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take? A. Contact the pharmacy and request the prescribed form of aspirin B. Instruct the client about the effects when given the medication C. Administer the aspirin with a full glass of water or a small snack D. Withhold the aspirin until consulting with the healthcare provider C. Administer the aspirin with a full glass of water or a small snack The nurse explains the 2-week dosage prescription of prednison (Deltasone) to a client who has poison ivy over multiple skin surfaces. What should the nurse emphasize about the dosing schedule? A. Decrease dosage daily as prescribed B. Monitor oral temperature daily C. Take the prednison with meals D. Return for blood glucose monitoring in one week C. Take the prednison with meals The nurse is preparing to administer a 1.2mL injection to a 4-year-old. Which are the best sites to administer an IM injection? Select all that apply. A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal D. Rectus femoris E. Deltoid A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal Which nonfood item is the most common cause of respiratory arrest in young children? A. Broken rattles B. Buttons C. Pacifiers D. Latex balloons D. Latex balloons A new mother is at the clinic with her 4-week old for a well baby check up. The nurse should tell the mother to anticipate that the infant will demonstrate which millstone by 2-months of age. A. Turns from side to back and returns B. Consistently returns smiles to mother C. Finds hands and plays with fingers D. Holds head up and supports weight with arms B. Consistently returns smiles to mother The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen and teh infusion rate is slower than the prescribed rate. What is the most likely cause of this finding? A. The solution's rate is too rapid B. The client has phlebitis C. The infusion site is infected D. The infusion site is infiltrated D. The infusion site is infiltrated The nurse observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement? A. Raise the bed to ensure the drainage bag remains off the floor B. Attach the drainage bag to the side rail instead of the bed frame C. Observe the appearance of the urine in the drainage tubing D. Secure the tubing to the client's gown instead of his abdomen C. Observe the appearance of the urine in the drainage tubing In assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next? A. Advise the client that suctioning will be used to obtain another specimen B. Re-instruct the client in coughing techniques to obtain another specimen C. Provide the client a glass of water and mouthwash to rinse the mouth D. Label the container and place the container in a bio-hazard transport bag B. Re-instruct the client in coughing techniques to obtain another specimen After report, the nurse receives the laboratory values for 4 clients. Which client requires the nurse's immediate intervention? The client who is..... A. short of breath after a shower and has a hemoglobin of 8 grams B. Bleeding from a finger stick and has a prothrombin time of 30 seconds C. Febrile and has a WBC count of 14,000/mm3 D. Trembling and has a glucose level of 50 mg/dL D. Trembling and has a glucose level of 50 mg/dL Upgrade to remove ads Only $3.99/month 4 hours after administration of 20U of regular insulin, the client becomes shakey and diaphoretic. What action should the nurse take? A. Encourage the client to excercise B. Administer a PRN dose of 10U of regular insulin C. Give the client crackers and milk D. Record the client's reaction on the diabetic flow sheet C. Give the client crackers and milk The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage? A. Place a 4X4 wick in the stoma opening B. Apply a layer of zinc oxide ointment to the perimeter of the stoma C. Cut the bag opening to the measurement of the stoma size D. Administer a PRN antidiarrheal agent C. Cut the bag opening to the measurement of the stoma size Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified? A. Temperature of 100.8F B. A pulse rate of 150 beats per minute C. A respiratory rate of 10 breaths per minute D. A blood pressure of 180/110 C. A respiratory rate of 10 breaths per minute Following an open reduction of the tibian, the nurse notes fresh bleeding on the client's cast. Which intervention should the nurse implement? A. Assess the client's hemoglobin to determine if the client is in shock B. Call the surgeon and prepare to take the client back to the operating room C. Outline the area with ink and check it q15 minutes to see if the area has increased D. No action is required since postoperative bleeding can be expected C. Outline the area with ink and check it q15 minutes to see if the area has increased The nurse is with a client when the healthcare provider explains that the biopsy classifies the results as a T1N0M0 tumor. Later in the morning, the client asks the nurse, "what do these letters T1N0M0, stand for?" which response should the nurse provide first? A. "The letters are used to predict the prognosis of the cancer or tumor." B. "The letters stand for tumor size, node involvement and metastasis." C. "Let me refer you to the charge nurse." D. "Are you confused? Would you like to talk?" B. "The letters stand for tumor size, node involvement and metastasis." The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding? what information should the nurse provide this client? A. The client should bottle feed and pump her breast for 3 days following immunization B. The vaccine is given to produce maternal antibodies before lactation occurs C. The infant will receive immunization through the mother's breast milk D. The client should not get pregnant for 3 months after immunization B. The vaccine is given to produce maternal antibodies before lactation occurs In counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse take? A. Recheck the radial pulse in thirty minutes B. Palpate the radial pulse for thiry seconds and double the rate C. Count the apical pulse rate for sixty seconds D. Compare the radial pulse rate bilaterally and record the higher rate. C. Count the apical pulse rate for sixty seconds Which structures are located in the subcutaneous layer of the skin? A. Sebaceous and sweat glands B. Melanin and Keratin C. Sensory receptors and hair follicles D. Adipose cells and blood vessels D. Adipose cells and blood vessels The nurse in charge of a Nursing unit in a long term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients? A. Measure the amount of a client's residual urine after voiding B. Cleanse the perineal area of a client with urinary incontinence C. Insert a straight catheter to obtain a urine specimen for culture D. Provide catheter care for a client with a suprapubic catheter B. Cleanse the perineal area of a client with urinary incontinence A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape in which direction to anchor the shield most effectively? A. Across the eye from the bridge of the nose to the right temple B. Longitudinally from the right forehead to the right cheek C. From the mid-forehead over to the right zygomatic process D. From the right lateral forehead surface to the medial nasal crease B. Longitudinally from the right forehead to the right cheek Upgrade to remove ads Only $3.99/month 36 hours after delivery, the nurse determines a client's fundus is just above the umbilicus and displaced to the right of midline. What action should the nurse take first? A. Palpate the bladder for distention B. Ask the client when her last bowel movement occurred C. Catheterize the client and record the amount D. Assess the amount of lochia A. Palpate the bladder for distention A client presents in the clinic because of generalized swelling after a bee sting. What intervention should the nurse implement first? A. Assess site of sting and remove stinger if present B. Perform mini-mental status exam to assess level of consciousness C. Determine respiratory status and apply a pulse oximeter D. Attach electrodes to monitor cardiac rhythm C. Determine respiratory status and apply a pulse oximeter The nurse is administering multiple medications to a 78-year-old client because of problems related to polypharmacy. At this client's age, which assessment is most important for the nurse to make? A. Cumulative serum drug levels and toxicity B. Synergistic actions due to simultaneous administration C. Tolerance to drugs that have been taken for long periods of time D. Antagonist actions of multiple medications A. Cumulative serum drug levels and toxicity In obtaining an orthostatic vital sign measurement, what action should the nurse take first? A. Count the client's radial pulse B. Apply a blood pressure cuff C. Instruct the client to lie supine D. Assist the client to stand upright C. Instruct the client to lie supine A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What interventions should the nurse expect to implement to establish hydration in the immediate postoperative period? A. Diaper weights and urin specific gravity B. Gastronomy feedings in supine position C. Nipple feedings with glucose water D. Gavage feedings with 15mL of formula C. Nipple feedings with glucose water Urinary catheter (Foley) with a 5mL inflated balloon is being removed by the nurse. After withdrawing 5 mL of fluid from the balloon, the nurse begins to withdraw the catheter while the client is in a SemiFowler's position. However, the nurse meets resistance and the clients voicees discomfort. What action should the nurse take next? A. Attempt to withdraw additional fluid from the balloon B. Assist the client in taking a series of deep breaths C. Lower the head of the client's bed so the client is supine D. Allow the client to rest before continuing to remove the catheter B. Assist the client in taking a series of deep breaths The home health nurse observes an elderly male client attempt to open a child-proof medication container. When he is unsuccessful in opening the container, he throws it across the room and curses loudly. What action should the nurse implement? A. Transfer the medications to another bottle that is easier to open B. Leave the client's home immediately and plan to return later C. Igonore the outburst and demonstrate how to open the bottle D. Describe other types of medication containers that are available D. Describe other types of medication containers that are available At 7AM, a Diabetic client is conscious with a serum glucose level of 50mg/dL. To manage this client's care effectively, what should the nurse administer? A. Orange juice B. Glucagon C. 10 units of regular insulin d. IV of 5% glucose in water at 100 mL/hr A. Orange juice A nurse is caring for a client with Multiple Sclerosis (MS) who is receiving an immunsupressant. Which action is most important for the nurse to implement to evaluate for adverse effects from this particular medication? A. Observe the client's skin for bruising B. Auscultate the client's bowel sounds C. Monitor the clients intake and output D. Note changes in the client's weight D. Note changes in the client's weight A male client with Hypercholesterolemia is being discharged with a new prescription for simvastatin (Zocor). The client tells the nurse that he understands it is important to have liver tests performed periodically. How should the nurse respond? A. Instruct the client that the only regular testing needed is to monitor his cholesterol level B. Teach the client that liver test are usually only done if the client reports symptoms C. Review with the client that renal function tests are needed, rather than liver tests D. Confirm that the client correctly understands the need to monitor liver function regularly D. Confirm that the client correctly understands the need to monitor liver function regularly An obese female client with a high serum cholesterol level comes to the clinic for a follow-up evaluation. She tells the nurse that she is now walking 30 minutes three times per week and is eating a carbohydrate free, high protein diet in order to lose weight. What response is best for the nurse to provide? A. Explain to the client that her diet choice is not helpful in lowering cholesterol levels B. Discuss the importance of maintaining a target heart rate during each exercise period C. Teach the client additional ways to lower cholesterol, including stress management D. Praise the client for her exercise and dieting efforts and encourage her to continue with this program A. Explain to the client that her diet choice is not helpful in lowering cholesterol levels A child with Chronic Asthma is scheduled for Chest Physiotherapy. When should the nurse administer the meter-dosed inhalar (MDI) puff of bronchodilator relative to postural drainage treatments? A. Before postural drainage B. During postural drainage C. After postural drainage D. Between treatements C. After postural drainage A client has a prescription for lorazepam (ativan) 1 mg for anxiety. The medication is supplied as 0.5mg tablets. How many tablets should the client take? (enter numeric value only.