NURS 207 ACTUAL HESI COMBINED EXAM
QUESTIONS AND ANSWERS. A+ ASSURED
2024 MOST RECENT UPDATE.
A client who is taking warfarin sodium for a deep vein thrombosis (DVT)
has an INR International randomized ratio level of 2. What interventions
should the nurse implement?
a. Administer PRN dose of vitamin K
b. Continue to administer the medication as scheduled
CONFIDENTIAL
c. Withhold the nest dose of warfarin
d. Resume warfarin when the INR is in therapeutic range
Rationale: An INR range of 2.0 to 3.0 is generally an effective
therapeutic range for people taking warfarin
An older adult resident of a long-term care facility has a 5-year history of
hypertension. The client has a headache and rate the pain 5 on a pain scale 0
to 10. The client’s blood pressure is currently 142/89. Which interventions
should the nurse implement? (Select all that apply)
[Date]
1
, a. Asses the client’s postural hypotension
b. Notify the healthcare provider immediately
c. Provide a PRN dose of acetaminophen for headache
d. Administer a daily dose of lisinopril as scheduled
e. Withhold the next scheduled daily dose of warfarin
Rationale: the client’ routinely scheduled medication, lisinopril, is an
antihypertensive medication and should be administered as scheduled to
maintain the client’s blood pressure. A PRN dose of acetaminophen
should be given for the client’s headache.
The other options are not indicated for this situation.
A client with Guillain-Barre syndrome has sensory loss and muscle
weakness that has ascended to the spinal level of t-4, and endotracheal
intubation is initiated to protect the client’s airway. The nurse notes that
an antianxiety medication was administered 2 hours ago. Which finding
indicates the medication was effective?
a. Sensory function improved in upper extremities
[Date]
2
, b. Muscle movement smooth without spasticity
c. No seizure activity observed in last 2 hours
d. Client responds calmly and appears relaxed
Before assisting the client with a morning shower an unlicensed assistive
personnel (UAP) reports that a client is feeling dizzy. The client’s vital signs
are: temperature 99.9, pulse 78 bpm, respirations 16 bpm, bp 84/60.
What action is best for the nurse to take?
a. Direct the UAP to give the client a bed bath
b. Suggest that the client’s shower be delayed another day
c. Ask the client if a tub bath is preferable
d. Instruct the UAP to obtain a shower chair
Rationale: taking a hot bath or shower can cause one's blood
vessels to dilate, lowering your blood pressure
[Date]
3
, Following a cataract extraction and intraocular lens implantation, a client
in the day surgery unit is reporting nausea. Which action is most important
for the nurse to Implement?
a. Administer a PRN antiemetic medication IV
b. Withhold the progression until nausea subsides
c. Position the client to use an emesis basin
d. Protec the operative eye from any risk for trauma
While changing the pressure ulcer dressing of a client who is immobile, the
nurse notes that the boundary edges of the wound have increased. Before
reporting the finding to the healthcare provider, the nurse should review
which of the client’s serum laboratory values?
a. Creatinine
b. Platelets
c. Potassium
[Date]
4
QUESTIONS AND ANSWERS. A+ ASSURED
2024 MOST RECENT UPDATE.
A client who is taking warfarin sodium for a deep vein thrombosis (DVT)
has an INR International randomized ratio level of 2. What interventions
should the nurse implement?
a. Administer PRN dose of vitamin K
b. Continue to administer the medication as scheduled
CONFIDENTIAL
c. Withhold the nest dose of warfarin
d. Resume warfarin when the INR is in therapeutic range
Rationale: An INR range of 2.0 to 3.0 is generally an effective
therapeutic range for people taking warfarin
An older adult resident of a long-term care facility has a 5-year history of
hypertension. The client has a headache and rate the pain 5 on a pain scale 0
to 10. The client’s blood pressure is currently 142/89. Which interventions
should the nurse implement? (Select all that apply)
[Date]
1
, a. Asses the client’s postural hypotension
b. Notify the healthcare provider immediately
c. Provide a PRN dose of acetaminophen for headache
d. Administer a daily dose of lisinopril as scheduled
e. Withhold the next scheduled daily dose of warfarin
Rationale: the client’ routinely scheduled medication, lisinopril, is an
antihypertensive medication and should be administered as scheduled to
maintain the client’s blood pressure. A PRN dose of acetaminophen
should be given for the client’s headache.
The other options are not indicated for this situation.
A client with Guillain-Barre syndrome has sensory loss and muscle
weakness that has ascended to the spinal level of t-4, and endotracheal
intubation is initiated to protect the client’s airway. The nurse notes that
an antianxiety medication was administered 2 hours ago. Which finding
indicates the medication was effective?
a. Sensory function improved in upper extremities
[Date]
2
, b. Muscle movement smooth without spasticity
c. No seizure activity observed in last 2 hours
d. Client responds calmly and appears relaxed
Before assisting the client with a morning shower an unlicensed assistive
personnel (UAP) reports that a client is feeling dizzy. The client’s vital signs
are: temperature 99.9, pulse 78 bpm, respirations 16 bpm, bp 84/60.
What action is best for the nurse to take?
a. Direct the UAP to give the client a bed bath
b. Suggest that the client’s shower be delayed another day
c. Ask the client if a tub bath is preferable
d. Instruct the UAP to obtain a shower chair
Rationale: taking a hot bath or shower can cause one's blood
vessels to dilate, lowering your blood pressure
[Date]
3
, Following a cataract extraction and intraocular lens implantation, a client
in the day surgery unit is reporting nausea. Which action is most important
for the nurse to Implement?
a. Administer a PRN antiemetic medication IV
b. Withhold the progression until nausea subsides
c. Position the client to use an emesis basin
d. Protec the operative eye from any risk for trauma
While changing the pressure ulcer dressing of a client who is immobile, the
nurse notes that the boundary edges of the wound have increased. Before
reporting the finding to the healthcare provider, the nurse should review
which of the client’s serum laboratory values?
a. Creatinine
b. Platelets
c. Potassium
[Date]
4
