Hesi exit 5 - 160 Questions and Answers
Suicide precautions are initiated for a child admitted to the mental health unit following
an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of
cigarettes in the client's room. Which intervention is most important for the nurse to
implement? ANSWERS-Remove cigarettes for the client's room
A family member of a frail elderly adult asks the nurse about eligibility requirements for
hospice care. What information should the nurse provide? (Select all that apply.)
A.)A client must be willing to accept palliative care, not curative care.
B.)The healthcare provider must project that the client has 6 months or less to live.
C.)The client must be diagnosed with clinical depression
D.)The client must be of sound mind ANSWERS-A,B
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction
should the nurse include in this client's teaching plan? ANSWERS-Avoid use of
nonsteroidal ant-inflammatory drugs (NSAID).
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is
irritable and diaphoretic with jugular vein distention. Which prescription should the nurse
administer first? ANSWERS-Digoxin
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse
(PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse
assign to the RN? ANSWERS-Supervise a newly hired graduate nurse during an
admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed asthma,
the client stares into the distance and appears to be concentrating on something other
than the lesson the nurse is presenting. What action should the nurse take?
ANSWERS-Ask the client what he is thinking about at his time.
After several hours of non-productive coughing, a client presents to the emergency
room complaining of chest tightness and shortness of breath. History includes end
stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While
completing the pulmonary assessment, the nurse hears wheezing and poor air
movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
A.)Administer PRN nebulizer treatment.
B.)Obtain 12 lead electrocardiogram.
,C.)Monitor continuous oxygen saturation.
D.) Lay the client in the prone position ANSWERS-A,B,C
The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the
infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest.
What action should the nurse take? ANSWERS-Administer a prescribed analgesia for
pain.
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT)
protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which
information should the nurse provide the parents about caring for their child?
ANSWERS-Use sunblock or protective clothing when outdoors.
Two days after admission a male client remembers that he is allergic to eggs, and
informs the nurse of the allergy. Which actions should the nurse implement? SATA
A.) Tell the client that its a mild reaction
B.)Notify the food services department of the allergy.
C.)Enter the allergy information in the client's record.
D.)Add egg allergy to the client's allergy arm band. ANSWERS-B,C,D
The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min
of continuous chest compressions. The client has a weak, fast pulse and no respiratory
effort, so the healthcare provider performs a successful oral, intubation. What action
should the nurse implement? ANSWERS-Perform bilateral chest auscultation.
After administering an antipyretic medication. Which intervention should the nurse
implement? ANSWERS-Encouraging liberal fluid intake
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which
explanation should be included in preparing this client for this treatment? ANSWERS-
Describe radioactive iodine as a tasteless, colorless medication administered by the
healthcare provider
After a colon resection for colon cancer, a male client is moaning while being
transferred to the Postanesthesia Care Unit (PACU). Which intervention should the
nurse implement first? ANSWERS-Determine client's pulse, blood pressure, and
respirations
, The nurse is caring for a group of clients with the help of a licensed practical nurse
(LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures
can the nurse delegate to the UAP? (Select all that apply)
A.)Take postoperative vital signs for a client who has an epidual following knee
arthroplasty
B.)Collect a sputum specimen for a client with a fever of unknown origin
C.)Ambulate a client who had a femoral-popliteal bypass graft yesterday ANSWERS-
A,B,C
A male client with cirrhosis has ascites and reports feeling short of breath. The client is
in semi Fowler position with his arms at his side. What action should the nurse
implement? ANSWERS-Raise the head of the bed to a Fowler's position and support
his arms with a pillow
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert
but has difficulty describing the exact nature and location of the pain to the nurse. Which
action should the nurse implement next? ANSWERS-Administer the analgesic as
requested
The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid
replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns
who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)
ANSWERS-12160
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values
indicate the client has thrombocytopenia. Based on this data, which nursing assessment
is most important following the procedure?
A.)Observe aspiration site.
B.)Assess body temperature
C.)Monitor skin elasticity
D.)Measure urinary output ANSWERS-A
An 18-year-old female client is seen at the health department for treatment of
condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV).
Which intervention should the nurse implement? ANSWERS-Reinforce the importance
of annual papanicolaou (Pap) smears.
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep
during the day, refuses to take a bath, and refuses to eat. Which nursing intervention
Suicide precautions are initiated for a child admitted to the mental health unit following
an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of
cigarettes in the client's room. Which intervention is most important for the nurse to
implement? ANSWERS-Remove cigarettes for the client's room
A family member of a frail elderly adult asks the nurse about eligibility requirements for
hospice care. What information should the nurse provide? (Select all that apply.)
A.)A client must be willing to accept palliative care, not curative care.
B.)The healthcare provider must project that the client has 6 months or less to live.
C.)The client must be diagnosed with clinical depression
D.)The client must be of sound mind ANSWERS-A,B
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction
should the nurse include in this client's teaching plan? ANSWERS-Avoid use of
nonsteroidal ant-inflammatory drugs (NSAID).
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is
irritable and diaphoretic with jugular vein distention. Which prescription should the nurse
administer first? ANSWERS-Digoxin
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse
(PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse
assign to the RN? ANSWERS-Supervise a newly hired graduate nurse during an
admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed asthma,
the client stares into the distance and appears to be concentrating on something other
than the lesson the nurse is presenting. What action should the nurse take?
ANSWERS-Ask the client what he is thinking about at his time.
After several hours of non-productive coughing, a client presents to the emergency
room complaining of chest tightness and shortness of breath. History includes end
stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While
completing the pulmonary assessment, the nurse hears wheezing and poor air
movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
A.)Administer PRN nebulizer treatment.
B.)Obtain 12 lead electrocardiogram.
,C.)Monitor continuous oxygen saturation.
D.) Lay the client in the prone position ANSWERS-A,B,C
The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the
infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest.
What action should the nurse take? ANSWERS-Administer a prescribed analgesia for
pain.
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT)
protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which
information should the nurse provide the parents about caring for their child?
ANSWERS-Use sunblock or protective clothing when outdoors.
Two days after admission a male client remembers that he is allergic to eggs, and
informs the nurse of the allergy. Which actions should the nurse implement? SATA
A.) Tell the client that its a mild reaction
B.)Notify the food services department of the allergy.
C.)Enter the allergy information in the client's record.
D.)Add egg allergy to the client's allergy arm band. ANSWERS-B,C,D
The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min
of continuous chest compressions. The client has a weak, fast pulse and no respiratory
effort, so the healthcare provider performs a successful oral, intubation. What action
should the nurse implement? ANSWERS-Perform bilateral chest auscultation.
After administering an antipyretic medication. Which intervention should the nurse
implement? ANSWERS-Encouraging liberal fluid intake
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which
explanation should be included in preparing this client for this treatment? ANSWERS-
Describe radioactive iodine as a tasteless, colorless medication administered by the
healthcare provider
After a colon resection for colon cancer, a male client is moaning while being
transferred to the Postanesthesia Care Unit (PACU). Which intervention should the
nurse implement first? ANSWERS-Determine client's pulse, blood pressure, and
respirations
, The nurse is caring for a group of clients with the help of a licensed practical nurse
(LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures
can the nurse delegate to the UAP? (Select all that apply)
A.)Take postoperative vital signs for a client who has an epidual following knee
arthroplasty
B.)Collect a sputum specimen for a client with a fever of unknown origin
C.)Ambulate a client who had a femoral-popliteal bypass graft yesterday ANSWERS-
A,B,C
A male client with cirrhosis has ascites and reports feeling short of breath. The client is
in semi Fowler position with his arms at his side. What action should the nurse
implement? ANSWERS-Raise the head of the bed to a Fowler's position and support
his arms with a pillow
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert
but has difficulty describing the exact nature and location of the pain to the nurse. Which
action should the nurse implement next? ANSWERS-Administer the analgesic as
requested
The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid
replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns
who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)
ANSWERS-12160
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values
indicate the client has thrombocytopenia. Based on this data, which nursing assessment
is most important following the procedure?
A.)Observe aspiration site.
B.)Assess body temperature
C.)Monitor skin elasticity
D.)Measure urinary output ANSWERS-A
An 18-year-old female client is seen at the health department for treatment of
condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV).
Which intervention should the nurse implement? ANSWERS-Reinforce the importance
of annual papanicolaou (Pap) smears.
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep
during the day, refuses to take a bath, and refuses to eat. Which nursing intervention
