HESI COMPREHENSIVE EXAM B(100% CORRECT QUESTION AND ANSWER)NEW!!! UPDATE

HESI COMPREHENSIVE EXAM B(100% CORRECT QUESTION AND ANSWER)NEW!!! UPDATE The nurse assesses a client who is taking indomethacin (Indocin) for arthritic pain. Which finding is most important to report to the primary health care provider? A. Takes medication with milk. B. Blood pressure, 104/64 mm Hg. C. Elevated liver enzyme levels. D. Hemoglobin level, 13 g/dL. - ANSWERS-C Rationale:Indomethacin is an antiinflammatory drug and can cause liver damage. Elevated liver enzyme levels indicate a complication with the drug. This medication should be taken with food or milk to reduce gastrointestinal (GI) side effects. Options B and D are normal findings. The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A. Suctions oral secretions from mouth B. Positions head of bed flat when changing sheets C. Takes temperature using the axillary method D. Keeps head of bed elevated at 30 degrees - ANSWERS-B Rationale:Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration. Options A, C, and D are all acceptable tasks performed by the UAP. When assessing safety for the older adult, which finding is the nurse's highest priority? A. The client has a cataract in the right eye. B. The client is not married and lives alone. C. The client lives in a two-story building. D. The client reports a history of repeated falls. - ANSWERS-D Rationale:Risk assessment for falls is a critical element in caring for the older adult. Options A, B, and C are important components in assessing client risk, but a history of prior falls puts the older client at very high risk for falling again. The nurse is assessing suicide risk for a client recently admitted to the acute psychiatric unit. Which finding is the most significant risk factor? A. High level of anxiety present B. History of previous suicide attempt C. Family history of depression D. Self-care deficit is noted. - ANSWERS-B Rationale:A previous history of a suicide attempt is the most significant risk factor for future suicide attempts because the client has previously implemented a plan. Options A, C, and D may also be risk factors but are not as significant as a history of previous attempts. A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test results indicate that the medication is producing the desired effect? A. Increased hemoglobin and hematocrit levels B. Increased serum calcium level C. Decreased white blood cell (WBC) count D. Decreased triiodothyronine (T3) and thyroxine (T4) levels - ANSWERS-D Rationale:Propylthiouracil (PTU) is an adjunct therapy used to control hyperthyroidism by inhibiting the production of thyroid hormones. It is often prescribed in preparation for thyroidectomy or radioactive iodine therapy. It does not affect option A. Option B must be monitored after surgery in case the parathyroid glands were removed, but preoperative PTU does not increase the serum calcium level. If the client has an infection preoperatively, antibiotics will be given and option C monitored. The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 lb. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The acetaminophen is available 150 mg/5 mL. How many mL will the nurse administer for one dose? _____ (Enter a whole number.) - ANSWERS-15 Rationale:66 lb/(2.2 kg/lb) = 30 kg30 kg × (15 mg/kg) = 450 mg(5 mL/150 mg) × 450 mg = 15 mLor(450 mg/150 mg) × 5 mL = 15 mL The nurse is planning care at the beginning of the shift. Which client will the nurse see first? A. The client who is waiting to go to the operating room B. The client who received a blood transfusion 4 hours ago C. The client awaiting transfer to the skilled unit D. The client with a new onset of a temperature of 102°F/38.9°C - ANSWERS-D Rationale:The change in the client's condition is the indication for the nurse's attention. The remaining clients have no indication that there is a change in condition.