Exit HESI Practice Questions and Answers 100% Solved

Exit HESI Practice Questions and Answers 100% Solved A client presents at the ED complaining of a raspy voice, cold intolerance, and fatigue. Lab tests indicate an elevated TSH and low T3 and T4 levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement? A) Assess for presence of non-pitting edema. B) Administer the prescribed dose of levothyroxine. C) Offer additional blankets and a warm drink. D) Note client's most recent hemoglobin levels. B) Administer the prescribed dose of levothyroxine. Rationale: In the negative feedback mechanism of hypothyroidism, a low level of thyroid hormone stimulates TSH production by the hypothalamus and results in an elevated TSH level, but the thyroid gland does not respond with adequate production of T3 and T4 to regulate basal metabolic rate. These serum hormone levels indicate the need to administer supplementary thyroid hormone as soon as possible to avert possible myxedema coma. Non-pitting edema is seen in chronic hypothyroidism and assessment of the presence and location of the edema (A) is not a top priority. Providing warmth (C) is beneficial but of less priority than (B). Anemia is common in hypothyroidism, but (D) is of lower priority than initiating treatment to prevent myxedema coma. The nurse suspects that a client might be hemorrhaging internally. Which findings of an orthostatic tilt test are a most likely indication of a major bleed (> 1000 ml)? A) A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of 20. B) A decrease in the systolic BP of 10 mm Hg with a corresponding decrease in the HR of 20. C) A decrease in the systolic BP of 20 mm Hg with a corresponding decrease in the HR of 10. D) A decrease in the systolic BP of 20 mm Hg with a corresponding increase in the HR of 10. Ans: A) A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of 20. Rationale: The loss of circulatory volume results in a 10 mm Hg drop in the systolic pressure, while the HR increases by 20 % above normal as a compensatory response to the low pressure. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? SATA. A) Canned fruit cocktail B) Creamy peanut butter C) Vegetable juice D) Vanilla frozen yogurt E) Clear beef broth Ans: C, D, E A full liquid diet includes all liquids that are not clear such as vegetable juice and frozen yogurt, as well as clear liquids. Pieces of fruit as found in fruit cocktail and peanut butter are not considered liquids. A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why he is prescribed all these medications? SATA. A) One of the medications is used to anesthetize the corneal surface. B) The iris must be paralyzed during the surgery to prevent it from reacting to light. C) Medication is used to induce sleep during the procedure. D) Pupillary dilation is necessary to access the eye chamber for lens removal. E) These meds assist in obstructing the client's vision during the surgery. Ans: A, B, D Cataract surgery is accessed through the cornea using eyelid retractors while the client is awake. It is necessary to anesthetize the corneal surface (A), paralyze the ciliary body (B), and provide pupil dilation (D)(mydriasis) to facilitate access to the lens which ties behind the iris (posterior chamber of the anterior cavity). A sedative may be administered to reduce anxiety but it is not used to induce sleep. (C) Cloudy vision may be a side effect of these agents, but the client will still be able to see during the surgery (E). When assessing an IV site that is sued for fluid replacement and medication administration, the client complains of the tenderness when the arm is touched above the site. Which additional assessment warrants immediate intervention by the nurse? A) Sluggish blood return B) Client uses the arm cautiously C) Spot of dried blood at the insertion site D) Red streak tracking the vein Ans: D A red streak (D) indicates vein irritation and necessitates discontinuing the IV at the present site. A, B, and C are indications for relocating the IV site or other immediate intervention. A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus? A) Blood cultures. B) Oxygen saturation. C) White blood count. D) Mean arterial pressure (MAP). D) Mean arterial pressure (MAP) The cornerstone of initial sepsis resuscitation is fluid volume administration to restore and then maintain MAP of at least 65 mmHg. When attempting to establish risk reduction strategies in a community, the nurse notes that regional studies indicate a high number of persons with growth stunting and irreversible mental deficiencies (cretinism) caused by hypothyroidism. The nurse should seek funding to implement which screening measure? A)T4 levels in newborns. B) TSH levels in women over 45. C) T3 levels in school-aged children D) Iodine levels in all persons over 60. A) T4 levels in newborns. Screening for low T4 levels in newborns with follow-up treatment can reduce the risk for irreversible growth stunting and mental deficiencies caused by congenital hypothyroidism. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? A) Loss of appetite B) Serum K+ 4.0 mEq/L or mmol/L (SI) C) Loose, runny stools. D) Tented skin turgor. D) Tented skin turgor. Indicates dehydration, a serious complication following prolonged diarrhea that requires further intervention by the nurse. A male client with ulcerative colitis received an Rx for a corticosteroid last month but because of the S/E, he stopped taking the medications 6 days ago. Which finding warrants immediate intervention by the nurse? A) Fluid retention B) Hypotension and fever C) Anxiety and restlessness D) Increased blood glucose B) Hypotension and fever Sudden withdrawal from a corticosteroid can cause sudden decreased adrenal function resulting in low serum sodium, high serum potassium, and low blood pressure which can lead to shock and possible death. Hypotension and fever (B) are the first signs of precipitous withdrawal. Fluid retention (A), anxiety and restlessness (C), and glucose intolerance (D) are common S/E of taking corticosteroids. The nurse who working in the ED is obtaining evidence for a rape kit from a woman who reports that she was raped. Which intervention is most important for the nurse to implement? A) Do not allow client to shower until all evidence is obtained. B) Report incident to the university's security department. C) Listen attentively to the client's description of the event. D) Determine the client's personal reaction to the reported rape. A) Do not allow client to shower until all evidence is obtained. It is most important to gather evidence and a shower distorts such evidence. The client should not be allowed to shower until all the evidence is collected. The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's HR drops to 60 bpm. Which action could the nurse take? A) Continue the insertion since this is a typical response. B) Insert the feeding tube into the infant's nasal passage. C) Pause and monitor for a continued drop of the HR D) Postpone the feeding until the infant's vital signs are stable. C) Pause and monitor for a continued drop of HR. Insertion of an orogastric tube for gavage feedings often triggers vagus stimulation which can result in bradycardia. Pausing during insertion and monitoring (C) the infant's HR and color may be all that is necessary for the HR to return to normal. A client who has a tracheal stoma is c/o of mouth pain. While performing oral care, nurse determines that the client has mouth ulcers and that oral mucosa is irritated. The client also has halitosis. Which intervention should the nurse implement? A) Encourage frequent use of mouthwash. B) Apply viscous gel to ulcers during mouth care. C) Provide flavored oral swabs to use Q2H D) Rinse out mouth with a liquid germicide daily. B) Apply viscous gel to ulcers during mouth care. Mouth ulcers and irritation of the lining of the mucous membranes are very painful. An oral viscous gel such as a lidocaine anesthetic can be used to temporarily relieve the pain. (B) Routine mouth care is necessary but should not be done too frequently because it may cause further irritation of the mucous membranes. An adult male is admitted in a rehab center after 3 weeks in an acute care hospital. The client suffered a R sided brain injury that occurred as the result of a fall from a ladder. Which intervention should the nurse include in this