HESI EXIT RN WELL ELLABORATED QUESTIONS AND ANSWERS [0VER 50 QUESTIONS 2023 PROPERLY ANSWERED

2. The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which action should the nurse take in response to the finding? Complete a thorough neurological assessment 3. Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter? Ensure continued sterility of the specimen container 4. The home health nurse observes an older client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. Which action should the nurse take? Hold the walker securely to prevent slipping while the client raises 5. A client with cancer complains of fever, chills, malaise, and headache following administration of a colony-stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu like symptoms? Monitor lab values for an increase in WBCs 6. Which laboratory value should the nurse review prior to administering the initial dose of a statin medication? Serum liver enzymes 7. Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure? I have a headache that gets worse when I sit up 8. The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a prescription for clonidine 0.2 mg PO taken twice daily. Which action should the nurse take? Advise to sit up slowly from a reclining position 9. A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history form the child's mother, the recent occurrence of what illness is most significant? Sore throat 10. Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is the best follow-up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream 11. The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe, colicky abdominal pain, nauseas, vomiting, and abdominal distention. Which pathophysiological mechanism supports the client's clinical presentation? A weakened diaphragm with high abdominal pressure 12. The nurse assesses a client with cirrhosis and find 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? Hypoalbuminemia that results in a decreased colloidal oncotic pressure 13. An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide to this client? Maintain prescribed eye drop regimen 14. The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? With atrial fibrillation whose saline lock is infiltrated 15. Penicillin G procaine 2,400,000 units intramuscularly is prescribed for a 4-year-old child who has streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2mL. How many mL should the nurse administer? 4 ML D/HX2ml 16. A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? Trendlenburg 17. A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While taking the blood pressure, the client begins to demonstrate cloudy consciousness, stupor, and has slurred speech. The nurse obtains blood glucose of 50 mg/dL, heart rate of 116 beats/minute, and blood pressure of 88/50 mmHg. Which intervention is most important for the nurse to implement? Position client with head flat and feet elevated 18. The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA) the nurse includes activities to strengthen and mobilize the joints surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? Exercise in the swimming pool 19. The nurse is educating a client with end-stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the clients daily diet? The protein intake should be decreased to prevent nitrogenous waste Buildup 20. A client is admitted to the hospital with symptoms consistent with a right hemispheric stroke. Which neurovascular assessment requires immediate intervention by the nurse? Unequal bilateral hand grip strengths 21. As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids on which pathophysiological process? Decreasing the formation and secretion of pancreatic enzymes 22. A male client being treated for testicular cancer with chemotherapy has decreased alpha fetoprotein radioimmunoassay (AFP). Which nursing intervention should the nurse implement? Advise the client that the treatment is having beneficial effect 23. The nurse plans to administer a bolus dose of IV heparin based on the clients weight. The prescribed bolus dose is 100 units/kg. The client weighs 198 pounds. How many units of Heparin sho