Exit HESI #1
The single mother of a child with a head injury is sitting at the child's bedside crying when
the PN enters the room. The mother states, "why did this happen? I just can't cope with this."
What is the best initial response - ANSDo you have someone who can help you cope with
this?
The PN is reinforcing instruction with a client who is being discharged from the ambulatory
day surgery center following cataracts removal and intraocular lens implants. Which
occurrence should the PN tell the client to report to HCP immediately - ANSNew visual
floaters or dots
The PN administer morphine sulfate 10 mg IM to a postop client. Before administering, the
PN should recognize the necessity for monitoring which parameter? - ANSDyspnea,
respiratory depth and rate
Student pregnancy is an issue. New prevention program was implemented. Which indicates
to the PN that the program is successful? - ANSStudents requesting information about
adolescent pregnancy has increased by 25%
Client who had endoscopic procedure in which local anesthetic was sprayed on throat. -
ANSaccess the gag reflex
PN is preparing to administer zolpidem prescribed PRN at HS for a male client. At 2100,
client states he is staying up 2 more hours and will put on call light when ready for med.
Which action should the PN take? - ANSPlan to return and administer the medication when
requested by the client
At 1200, the PN learns that clients 0900 dose of an anticonvulsant was not given. Next dose
is at 2100. Which action should the PN take? - ANSAdminister the missed dose asap
A client on bedrest refuses to wear the prescribed pneumatic compression devices after
surgery. Which action should the PN implement in response to the client's refusal?
A. Emphasize the importance of active foot flexion
B. Check the surgical dressing
C. Complete an incident report
D. Explain the use of incentive spirometer q2 hours - ANSexplain the use of the incentive
spirometer q2h
Which action should the PN take while caring for a client who is experiencing spiritual
distress? - ANSDetermine the clients beliefs system
, During prenatal visit, the PN discusses with a client the effects of smoking of her fetus.
Which is most common problem among neonates whose mother's smoked during pregnacy -
ANSLow birth weights
The PN is caring for a 9 month infant with developmental dysphasia of the hip (ddh) after a
closed reduction and hip spica cast application. After cast application, which is the most
important intervention in caring for the intervention? - ANSmonitor toes for movement,
sensation, and circulation
While administering oxygen to an infant with Tetralogy of Fallot (TOF) who is having a
hypoxic episode, the PN should implement which implement? - ANSHold the infant in a
knee-position
The PN is assigned care for an older adult male client who is recovering from a stroke.
When assisting client to ambulate with the use of a cane, where should the PN place the
cane in relation to the client's body? - ANSOn the opposite side of the affected extremity
The PN plans to collect a urine specimen for culture and sensitivity. Why should the client be
instructed to collect the specimen using a clean-catch or midstream technique. - ANSTo
wash the external genitalia of organisms that may contaminate the specimen
The PN is assisting with the care of a newborn who received erythromycin ointment eye
prophylaxis 24 ago. Which finding should the PN report to the charge nurse. - ANSSwollen
eyelids bilaterally
An older adult is admitted to the hospital because of an adverse drug reaction related to
polypharmacy. Which information is most important for the PN to collect during the
admission process? - ANSPharm and herbal supplement use
Before administering a antibiotic that can cause nephrotoxicity, which lab value is most
important for the PN to review? - ANSSerum creatinine
During a daily assessment in the nursey, the PN notices three large bluish-black areas on
the back and buttocks of an African American infant. Which action should the PN take? -
ANSreview the labor and delivery record for birth truama
The PN is assigned to care for four clients and needs to assign the care of one of the clients
to the UAP. Which clients should teh PN assign to the UAP - ANSA cleint with paraplegia
who is transferring to a skilled nursing facility tomorrow
When administering a saline enema, the PN inserts the enema tubing 3 in into client's
rectum and elevates the container 6 inches above the clients body. When the clamp opens
and the solution does not infuse. Which action should the PN first? - ANSRaise the saline
container 6 in higher
A 2 day old infant with hydrocephalus return from surgery following placement of a
ventriculoperitoneal shunt. Which nursing interventions should the PN implement during post
op care? Select all that apply - ANS
The single mother of a child with a head injury is sitting at the child's bedside crying when
the PN enters the room. The mother states, "why did this happen? I just can't cope with this."
What is the best initial response - ANSDo you have someone who can help you cope with
this?
The PN is reinforcing instruction with a client who is being discharged from the ambulatory
day surgery center following cataracts removal and intraocular lens implants. Which
occurrence should the PN tell the client to report to HCP immediately - ANSNew visual
floaters or dots
The PN administer morphine sulfate 10 mg IM to a postop client. Before administering, the
PN should recognize the necessity for monitoring which parameter? - ANSDyspnea,
respiratory depth and rate
Student pregnancy is an issue. New prevention program was implemented. Which indicates
to the PN that the program is successful? - ANSStudents requesting information about
adolescent pregnancy has increased by 25%
Client who had endoscopic procedure in which local anesthetic was sprayed on throat. -
ANSaccess the gag reflex
PN is preparing to administer zolpidem prescribed PRN at HS for a male client. At 2100,
client states he is staying up 2 more hours and will put on call light when ready for med.
Which action should the PN take? - ANSPlan to return and administer the medication when
requested by the client
At 1200, the PN learns that clients 0900 dose of an anticonvulsant was not given. Next dose
is at 2100. Which action should the PN take? - ANSAdminister the missed dose asap
A client on bedrest refuses to wear the prescribed pneumatic compression devices after
surgery. Which action should the PN implement in response to the client's refusal?
A. Emphasize the importance of active foot flexion
B. Check the surgical dressing
C. Complete an incident report
D. Explain the use of incentive spirometer q2 hours - ANSexplain the use of the incentive
spirometer q2h
Which action should the PN take while caring for a client who is experiencing spiritual
distress? - ANSDetermine the clients beliefs system
, During prenatal visit, the PN discusses with a client the effects of smoking of her fetus.
Which is most common problem among neonates whose mother's smoked during pregnacy -
ANSLow birth weights
The PN is caring for a 9 month infant with developmental dysphasia of the hip (ddh) after a
closed reduction and hip spica cast application. After cast application, which is the most
important intervention in caring for the intervention? - ANSmonitor toes for movement,
sensation, and circulation
While administering oxygen to an infant with Tetralogy of Fallot (TOF) who is having a
hypoxic episode, the PN should implement which implement? - ANSHold the infant in a
knee-position
The PN is assigned care for an older adult male client who is recovering from a stroke.
When assisting client to ambulate with the use of a cane, where should the PN place the
cane in relation to the client's body? - ANSOn the opposite side of the affected extremity
The PN plans to collect a urine specimen for culture and sensitivity. Why should the client be
instructed to collect the specimen using a clean-catch or midstream technique. - ANSTo
wash the external genitalia of organisms that may contaminate the specimen
The PN is assisting with the care of a newborn who received erythromycin ointment eye
prophylaxis 24 ago. Which finding should the PN report to the charge nurse. - ANSSwollen
eyelids bilaterally
An older adult is admitted to the hospital because of an adverse drug reaction related to
polypharmacy. Which information is most important for the PN to collect during the
admission process? - ANSPharm and herbal supplement use
Before administering a antibiotic that can cause nephrotoxicity, which lab value is most
important for the PN to review? - ANSSerum creatinine
During a daily assessment in the nursey, the PN notices three large bluish-black areas on
the back and buttocks of an African American infant. Which action should the PN take? -
ANSreview the labor and delivery record for birth truama
The PN is assigned to care for four clients and needs to assign the care of one of the clients
to the UAP. Which clients should teh PN assign to the UAP - ANSA cleint with paraplegia
who is transferring to a skilled nursing facility tomorrow
When administering a saline enema, the PN inserts the enema tubing 3 in into client's
rectum and elevates the container 6 inches above the clients body. When the clamp opens
and the solution does not infuse. Which action should the PN first? - ANSRaise the saline
container 6 in higher
A 2 day old infant with hydrocephalus return from surgery following placement of a
ventriculoperitoneal shunt. Which nursing interventions should the PN implement during post
op care? Select all that apply - ANS
