HESI 799 RN EXIT EXAM (709-810)-87 QUESTIONS WITH VERIFIED SOLUTIONS 2024

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement? a. Obtain the results for STAT serum cardiac biomarkers b. Asses for contraindications for thrombolytic therapy c. Measure ST-segment height and waveform changes. d. Transfer for percutaneous coronary intervention (PCI) b. Asses for contraindications for thrombolytic therapy. A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse? a. Pale pink urine output b. Dark red clot in urine c. Leakage around catheter insertion site d. Urinary output greater than 90 ml/hour. c. Leakage around catheter insertion site 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.) A. Headache and tremors. B. Postural hypotension. C. Pallor and diaphoresis. D. Skin hyperpigmentation. E. Irregular heart beat. A. Headache and tremors. B. Postural hypotension. C. Pallor and diaphoresis. E. Irregular heart beat. A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care? a. Monitor deep vein blood flow using Doppler b. Evaluate daily blood clotting factors. c. Apply antiembolism stockings. d. Maintain strict bed rest. b. Evaluate daily blood clotting factors. The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first? a. Administer schedule medications b. Offer the client PRN anxiolytic c. Assess the lungs for wheezing d. Evaluate the oxygen saturation. d. Evaluate the oxygen saturation. During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide? a. The immunosuppressant medication will be increased until the rejection subside b. Dialysis may be necessary until the chronic rejection can be reversed. c. Dialysis would need to be resumed if chronic rejection becomes a reality d. A different combination of immunosuppressant medications will be implemented. c. Dialysis would need to be resumed if chronic rejection becomes a reality The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first? a. Provide the gloves for the UAP to apply b. Offer to help reposition the client c. Instruct the UAP to raise the bed level d. Place the side rails in an up position d. Place the side rails in an up position A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication? a. Chest pain and dysrhythmia b. Vasodilation of the extremities c. Hypotension and tachycardia d. Decreasing GI cramping and nausea. a. Chest pain and dysrhythmia A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make? a. Contact the healthcare provider immediately to report the laboratory value regardless of the advice. b. Call the lab to draw an additional blood sample for a repeat evaluation of the potassium level STAT. c. Flag the client's medical record to alert the healthcare provider immediately upon arrival to the unit. d. Ask the charge nurse to contact the healthcare provider with the laboratory results by mid-morning. a. Contact the healthcare provider immediately to report the laboratory value regardless of the advice. A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste "bitter". He complains that he simply has no appetite. What action should the nurse implement? a. Instruct the client to add ground beef and chicken in small amount to casseroles. b. Encourage the client to try to eat these foods in moderation despite the taste c. Advise the client to replace the bitter-tasting foods with fruits and vegetables. d. Suggest the use of alternative sources of protein such as dairy products and nuts. d. Suggest the use of alternative sources of protein such as dairy products and nuts. A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication? A. Pulse rate of 62 B. Potassium level of 3.2 C. Blood pressure 90/76 mm Hg D. Blood Pressure 160/92 mm Hg C. Blood pressure 90/76 mm Hg The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? a. Recommend weigh bearing physical activity b. Reduce intake of foods high in vitamin D c. Decrease intake of foods high in fat d. Minimize heavy lifting and bending. a. Recommend weigh bearing physical activity Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately? A. Blood tinged sputum B. Expiratory wheezing C. Upper airway stridor D. Oxygen saturations 90% C. Upper airway stridor During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage A. natural whole almonds B. lightly salted potatoe chips C. Cheddar cheese cubes D. Canned fruits in heavy syrup E. plain, air-popped popcorn A. Natural whole almonds E. Plain, air-popped popcorn A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? A. Regular insulin. B. Hydrocortisone C. Broad spectrum antibiotic D. Potassium chloride B. Hydrocortisone An adolescent, whose mother recently died, comes to the school nurse complaining of a headache. Which statement made by the students should warrant further explanation by the nurse? A. "I've had dreams about Mon since she died." B. "I've been very sad and cry a lot at night." C. "I miss Mom and would like to go see her'". D. " it's hard to concentrate on my homework" C. "I miss Mom and would like to go see her'". A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse? A. Prepare for transcutaneous pacing B. Administer IV epinephrine per ACLS protocol. C. Give IV dose of adenosine rapidly over 1-2 seconds. D. Deliver another defibrillator shock. C. Give IV dose of adenosine rapidly over 1-2 seconds. A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? A. Identify local support HIV support groups. B. Assess for symptoms of AIDS dementia. C. Observe for adverse drug reaction. D. Monitor for secondary infections. D. Monitor for secondary infections. The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? A. Stopper port located above the water-seal level B. Plastic tubing located at the chest insertion site C. Rubberized port at the bottom of collection chamber D. Tubbing located on the top of the suction chamber B. Plastic tubing located at the chest insertion site While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? A. Apply ice first, then a warm compress to the IV site B. Discontinue the painful IV after a new IV is inserted C. Review the medical record for the date of insertion D. Document that the medication was not administered B. Discontinue the painful IV after a new IV is inserted An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure should the nurse prepare for first? A. Insertion of a left- sided chest tube. B. Placement of an endotracheal tube. C. Retraction of the nasogastric tube D. Setup of patient- controlled analgesia A. Insertion of a left- sided chest tube. During a staff meeting, a nurse verbally attacks the nurse manager conducting the meeting, stating, "you always let your favorites have holidays off give then easier assignments. You are unfair and prejudiced" how should the nurse-manager respond? A. I would prefer to discuss this with you privately. B. Give me specific examples to support your statements. C. Does anyone else on the staff fell the same way D. Your remarks are not true and are very unkind B. Give me specific examples to support your statements. A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement? A. Space care to provide periods of rest B. Instruct client to purse lip breathe C. Administer PRN dose of albuterol D. Position client for maximum comfort C. Administer PRN dose of albuterol A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine B. Furosemide