HESI EXIT EXAM
1. A client tells the nurse that he is suffering from insomnia. Which
information is most important for the nurse to obtain?
A. The client's usual sleeping pattern
B. Whether the client smokes
C. How much liquid the client consumes
before bedtime
D. The amount of caffeine that the client
consumes during the day
Rationale:
The first thing to determine is the client's usual sleeping pattern and how
it has changed to become what the client describes as insomnia. Options
B, C, and D provide additional information after option A is ascertained.
2. A client has been on a mechanical ventilator for several days. What
should the nurse use to document and record this client's
respirations?
A. The respiratory settings on the ventilator
B. Only the client's spontaneous respirations
C. The ventilator-assisted respirations minus
the client's independent breaths
D. The ventilator setting for respiratory rate
and the client-initiated respirations
Rationale:
The nurse should count the client's respirations and document both the
respiratory rate set by the ventilator and the client's independent
respiratory rate. Never rely strictly on option A. Although the client's
, spontaneous breaths will be shallow and machine-assisted breaths will
be deep, it is important to record machine-assisted breaths as well as the
client's spontaneous breaths to get an overall respiratory picture of the
client.
3. Six hours following thoracic surgery, a client has the following
arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg;
HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention should the
nurse implement based on these results?
A. Increase the oxygen flow rate from 4 to 10
L/min per nasal cannula.
B. Assess the client for pain and administer
pain medication as prescribed.
C. Encourage the client to take short shallow
breaths for 5 minutes.
D. Prepare to administer sodium bicarbonate
IV over 30 minutes.
Rationale:
These ABGs reveal respiratory alkalosis, and treatment depends on the
underlying cause. Because the client is only 6 hours postoperative, he or
she should be assessed for pain because treating the pain will correct the
underlying problem. A PaO2 of 96 mm Hg does not indicate the need for
an increase in oxygen administration. The PaCO2 indicates mild
hyperventilation, so option C is not indicated. In addition, it is very
difficult to change one's breathing pattern. The use of sodium
bicarbonate is indicated for the treatment of metabolic acidosis, not
respiratory alkalosis.
4. A 77-year-old female client states that she has never been so large
around the waist and that she has frequent periods of constipation.
Colon disease has been ruled out with a flexible sigmoidoscopy.
Which information should the nurse provide to this client?
1. A client tells the nurse that he is suffering from insomnia. Which
information is most important for the nurse to obtain?
A. The client's usual sleeping pattern
B. Whether the client smokes
C. How much liquid the client consumes
before bedtime
D. The amount of caffeine that the client
consumes during the day
Rationale:
The first thing to determine is the client's usual sleeping pattern and how
it has changed to become what the client describes as insomnia. Options
B, C, and D provide additional information after option A is ascertained.
2. A client has been on a mechanical ventilator for several days. What
should the nurse use to document and record this client's
respirations?
A. The respiratory settings on the ventilator
B. Only the client's spontaneous respirations
C. The ventilator-assisted respirations minus
the client's independent breaths
D. The ventilator setting for respiratory rate
and the client-initiated respirations
Rationale:
The nurse should count the client's respirations and document both the
respiratory rate set by the ventilator and the client's independent
respiratory rate. Never rely strictly on option A. Although the client's
, spontaneous breaths will be shallow and machine-assisted breaths will
be deep, it is important to record machine-assisted breaths as well as the
client's spontaneous breaths to get an overall respiratory picture of the
client.
3. Six hours following thoracic surgery, a client has the following
arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg;
HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention should the
nurse implement based on these results?
A. Increase the oxygen flow rate from 4 to 10
L/min per nasal cannula.
B. Assess the client for pain and administer
pain medication as prescribed.
C. Encourage the client to take short shallow
breaths for 5 minutes.
D. Prepare to administer sodium bicarbonate
IV over 30 minutes.
Rationale:
These ABGs reveal respiratory alkalosis, and treatment depends on the
underlying cause. Because the client is only 6 hours postoperative, he or
she should be assessed for pain because treating the pain will correct the
underlying problem. A PaO2 of 96 mm Hg does not indicate the need for
an increase in oxygen administration. The PaCO2 indicates mild
hyperventilation, so option C is not indicated. In addition, it is very
difficult to change one's breathing pattern. The use of sodium
bicarbonate is indicated for the treatment of metabolic acidosis, not
respiratory alkalosis.
4. A 77-year-old female client states that she has never been so large
around the waist and that she has frequent periods of constipation.
Colon disease has been ruled out with a flexible sigmoidoscopy.
Which information should the nurse provide to this client?
