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Exam (elaborations)

ALL HESI EXIT Questions and Answers 2022 Test Bank - Rated A+

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A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take? (correct Answer- Administer the medication as prescribed with a glass of water Which client should the nurse assess frequently because of the risk for overflow incontinence? A client Who is confused and frequently forgets to go to the bathroom While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply) (correct Answer-

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HESI EXIT 2022 Test Bank



ALL HESI EXIT Questions and Answers
2022 Test Bank; A+ Rated Guide

,A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action
should the nurse take?



(correct Answer- Administer the medication as prescribed with a glass of water



Which client should the nurse assess frequently because of the risk for overflow incontinence?



A client Who is confused and frequently forgets to go to the bathroom



While monitoring a client during a seizure, which interventions should the nurse implement? (Select all
that apply)



(correct Answer-

Move obstacle away from client Monitor physical movements Observe for a patent airway Record the
duration of the seizure



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?



(correct Answer- Observe for changes in level of consciousness.



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?

correct Answer- Increase 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?

,(correct Answer- CPT should be performed more frequently, but at least an hour before 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?



(correct Answer- Baked pork chop, applesauce, corn on the cob, 2% milk, and key- lime pie



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?

(correct Answer- Fingerstick glucose assessment q6h with meals Review with the client proper foot care
and prevention of injury

Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous
injection technique, site rotation and insulin management



Which problem reported by a client taking lovastatin requires the most immediate fallow up by the
nurse?

(correct Answer- Muscle pain

While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the
chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120
beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should
the nurse implement?

(correct Answer- Provide supplemental oxygen Auscultate bilateral lung fields

Reinforce occlusive CT dressing

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach
the client's wrist restraints to the movable portion of the client's bed frame. What action should the
nurse take before leaving the room?



(correct Answer- Ensure that the knot can be quickly released.

Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and
benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse
emphasize concerning the installation of the antipyrine/benzocaine otic solution?

(correct Answer- Have the child lie with the ear up for one to two minute after installation.

, An older adult male is admitted with complications related to chronic obstructive pulmonary disease
(COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over
the past month. The nurse notes that he has dependent edema in both lower legs. Based on these
assessment findings, which dietary instruction should the nurse provide?

(correct Answer- Restrict daily fluid intake.



The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take
next?



(correct Answer- Leave the catheter in place and obtain a sterile catheter.

A client with coronary artery disease who is experiencing syncopal episodes is admitted for an
electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the
nurse delegate to the unlicensed assistive personnel (UAP)?



(correct Answer- Prepare the skin for procedure.

Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most
important for the school nurse to take?

(correct Answer- Restrict unvaccinated children from attending school until measles outbreak is
resolved.



A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She
continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per
hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse
implement?

(correct Answer- Continue with the plan of care for this client

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior
indicates the highest risk for the client acting on these suicidal thoughts?

(correct Answer- Begin to show signs of improvement in affect



When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia
rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse
implement first?

(correct Answer- Check for a destined bladder

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