HESI RN EXIT REAL EXAM 300+ QUESTIONS AND CORRECT ANSWERS WITH RATIONALES LATEST UPDATES

HESI RN EXIT REAL EXAM 300+ QUESTIONS AND CORRECT ANSWERS WITH RATIONALES LATEST UPDATES While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement? -answer- Promptly remove the arterial catheter from the radial artery. A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascularsource of the intracranial bleeding, which finding should the nurse monitor? -answer- Rapid onset of decreased level of consciousness. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan? -answer- Report any signs of cloudy urine output. After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take? -answer- Apply light pressure over the area. The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture. What action should the nurse take? -answer- Reposition the restraint tie onto the bedframe. A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse? -answer- Diminished lef t lower lobe sounds Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re-inflate the lung. The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom) -answer- Arterial endothelium injury causes inflammation Macrophages consume low density lipoprotein (LDL), creating foam cells Foam cellsrelease growth factors forsmooth muscle cells HESI RN EXIT REAL EXAM 300+ QUESTIONS AND CORRECT ANSWERS WITH RATIONALES LATEST UPDATES Smooth muscle grows over fatty streaks creating fibrous plaques Vessel narrowing results in ischemia Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider? -answer- Oliguria signalstubular necrosis related to hypoperfusion A nurse-manager is preparing the curricula for a classfor charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective? -answer- Skills of staff and client acuity When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? -answer- Explain that the client may be placed in five positions A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke? -answer- Inability to close the affected eye, raise brow, or smile The nurse is teaching a client how to perform colostomy irrigations. When observing the client'sreturn demonstration, which action indicated that the client understood the teaching? -answer- Keeps the irrigating container less than 18 inches above the stoma