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HESI EXIT RN 2023 V3 160 Questions with answers

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HESI EXIT RN 2023 V3 160 Questions with answers 1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? 2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the - 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? 3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? 4. A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation. Based on the client’s admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) 5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? 6. After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? 7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective? 8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? 9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? 10. An older adult male who is in his early 70’s is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client’s living will. Which action should the nurse take? 11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? ...............................................continued..................................................

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HESI
EXIT RN
2023 V3
160
Questions
with

,answers

,1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One
hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the
client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to
reporting the finding to the surgeon. Which action should the nurse implement first?




a. Measure and document the client’s urinary output.




b. Request the client’s reserved unit if packed red blood cells.




c. Prepare the placement of a central

venous catheter. d. Increase the infusion rate of Lactated
Ringer’s solution.




2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to
the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at
the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red
blood is measured in the collection chamber. Which intervention should the nurse implement?




a. Add sterile water to the suction control chamber.

, b. Give blood from the collection chamber as autotransfusion




c. Manipulate blood in tubing to drain into chamber.




d. Increase wall suction to eliminate fluctuation in water seal.




3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room
air of 89%. Which action should the nurse take first?




a. Elevate the foot of the bed.




b. Restrict

the client’s fluid. c. Begin
supplemental oxygen.
d. Prepare the client for hemodialysis.
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