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

271. 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 272. 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 273. 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 274. 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. 275. 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. 276. 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. 277. The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendationfor hypertension? (correct Answer- Baked pork chop, applesauce, corn on the cob, 2% milk, and key- lime pie 278. 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 279. Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse? (correct Answer- Muscle pain 280. 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 281. 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. 282. 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. 283. 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. 284. 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. 285. 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. 286. 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. 287. 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 288. 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 289. 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 290. A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? (correct Answer- Encourage popsicles and fluids of choice 291. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? (correct Answer- Palpate the client's suprapubic area for distention 292. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include? (correct Answer- Divide the medication into two injection with volumes under 1ml 293. A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? (correct Answer- Research indicates that mirror therapy is effective in reducing phantom limb pain 294. An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? (correct Answer- Notify healthcare provider to prepare for pericardiocentesis 295. A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take? (correct Answer- Ask the new person to move belonging to accommodate others 296. The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? (correct Answer- Poor feeding and vomiting Leakage of CSF from the incisional site Abdominal distention 297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only) ( correct Answer- 8 298. In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care? (correct Answer- Evaluate closet proximal pulse. 299. The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take? (correct Answer- Remove the heating pads and place a soft blanket over the client's leg and feet. 300. A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client? (correct Answer- Plan volume-controlled evenly- space meal thorough the day 301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? (correct Answer- Insensible loss of body fluids contributes to the hemoconcentration of serum solutes 302. During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN) (correct Answer- Prepare a woman for a bone density screening 303. An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take? (correct Answer- Send family to the waiting area while the client's history is taking