hesi exam version 1 2022 ACCURATE TESTED VERSIONS OF THE EXAM FROM 2023TO 2024 | ACCURATE AND VERIFIED | NEXT GEN FORMAT | GUARANTEED PASS

The nurse is assessing a male with a history of Addison's disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The health care provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed? a. Hypertonic saline solution at 100 ml/hr until all edema disappears b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg c. Potassium chloride 20 mEq IV to infuse over 2 hours until confusion resolves d. Regular insulin drip to keep blood glucose around 100 mg/dl (5.55 mmol/L) b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg emergency treatment for acute adrenal insufficiency (addisonian crisis) is IV infusion of hydrocortisone and saline solution. the client is usually given a dose containing hydrocortisone 100 mg IV in normal saline every 6 hours until the client's blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemia. The client needs normal- not hypotonic- saline solution A client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which intervention should the nurse include in the client's plan of care? Select all that apply. a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs c. Schedule rest periods between activities d. Maintain record of fluid intake and output e. Initiate contact transmission precautions a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs c. schedule rest periods between activities d. maintain a record of fluid intake and output A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. the child smells of chemicals on the hands, face, and on the front of the child's clothes. after ensuring the airway is patent, what action should the nurse implement first? a. Assess the child for altered sensorium b. Determine type of chemical exposure c. Obtain equipment for gastric lavage d. Call poison control emergency number b. Determine type of chemical exposure Rationale: once the type of chemical is determined, poison control should be called even if the chemical is unknown. if lavage is recommended by poison control, intubation, and nasogastric tube may be needed as directed by poison control. Altered sensorium, such as lethargy, may occur if hydrocarbons are ingested. Which conditions are most likely to respond to treatment with antihistamines? Select all that apply. a. Bronchitis b. Allergic rhinitis c. Otitis media d. Contact dermatitis e. Myocarditis b. Allergic rhinitis d. Contact dermatitis antihistamines are commonly used to alleviate symptoms such as sneezing, itching, and runny nose associated with allergic rhinitis antihistamines may help relieve itching and some symptoms associated with contact dermatitis An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which action should the nurse take? Select all that apply. a. Ask if the mother is experiencing any pain with urination b. Encourage increased intake of high protein foods c. Instruct the daughter to check her mother's temperature d. Review the client's current food and medication allergies e. Determine if the mother has recently experienced a fall a. Ask if the mother is experiencing any pain with urination c. Instruct the daughter to check her mother's temperature e. Determine if the mother has recently experienced a fall urinary tract infections can cause sudden changes in behavior and confusion in older adults; pain with urination is a symptom of uti fever can be a sign of infection, which can contribute to confusion in older adults falls can lead to head injuries or fractures; which may result in changes in mental status; it is important to assess for any trauma infective endocarditis can lead to complications such as emboli, and monitoring the cardiac rhythm is important to detect any arrhythmias or changes changes in heart murmurs can indicate further damage to the heart valves and may be indicative of complications related to infective endocarditis Rest is important to reduce cardiac workload and promote healing Monitoring fluid balance is crucial, especially if the client is experiencing heart failure or complications related to infective endocarditis Pregnancy Induced Hypertension - ANSWER High Blood Pressure Blurred Vision Headache Proteinuria Abdominal Pain A client is comatose upon arrival to the emergency room department after falling from the roof. The client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's airway. - ANSWER nasopharyngeal tube. A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first? - ANSWER Assess the client for pallor Risk management: pt fell while using some equipment... charge nurse trying to find out what happened- how? - ANSWER hospital polices The nurse is assessing a 48-year-old client with Guillain-Barre syndrome. What symptom is this client most likely to exhibit? - ANSWER Decreased mobility of the legs. Preop pt should be npo and pt had a glass of h2o-what to do - ANSWER Alert surgeon/physician. A client experiencing intracranial hypertension from a traumatic brain injury is admitted to the trauma unit. How should the nurse position the client? - ANSWER Elevate the head of bed. The nurse is caring for a client diagnosed with myasthenia gravis. Which nursing action is best to promote independence in this client - ANSWER Teach the client and family energy conservation techniques. The nurse is assessing a 2-week-old breastfeeding infant. To obtain information about the adequate nutrition, which question should the nurse ask the breastfeeding mother? - ANSWER "How many diapers does the infant wet daily?" Zyvox & suprainfection - ANSWER Stomatitis Potassium Chloride - ANSWER Client able to void, assuring kidney function is present. The nurse has identified four nursing problems for a 13-year-old admitted for depression and anxiety. What is the priority problem? - ANSWER Risk for self directed violence related to history of self multilation. The nurse is teaching a client newly diagnosed with diabetes mellitus the signs of hypoglycemia. What symptom should be included in the description of early signs of hypoglycemia? - ANSWER Tremors (Audio/visual)- ask to hear heart sounds - ANSWER murmur (know difference between S1/S2 sounds When you are giving asthma med... which one would you give first? - ANSWER Bronchodilator then steroid verbalize ways to decrease blood pressure." What statement by the client indicates that this outcome has been met? - ANSWER "if I loose weight, quit smoking, and exercise regularly I may not have to take any medication. (Select all that apply) Determining pain level for 3mo old infant- infant will clinch fists, - ANSWER infant will clinch fists increase pulse restlessness increased respiratory effort Penicillin G procaine (Wycillin) 135,000 units IM is prescribed for an infant with a middle ear infection. The drug is available in a vial of 1,200,000 units /2ml. How many ml should the nurse administer? - ANSWER 0.23 ml Depressed client and best activity - ANSWER Assist client with making cut out cookies The nurse is teaching a client's caregiver how to cleanse around a wound drain. What is the besy way to explain the proper cleansing technique? - ANSWER Start at the drain site, to avoid bringing skin bacteria toward the wound. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator. What action should the nurse implement? - ANSWER Wear a dosimeter film badge. Alupent administration- The usual single dose is two to three inhalations. With repetitive dosing, inhalation should usually not be repeated more often than about every three to four hours. Total dosage per day should not exceed 12 inhalations. - ANSWER Alupent (metaproterenol sulfate USP) Inhalation aerosol is not recommended for children under 12 years of age. In scheduling home visits, which client is best for the home health charge nurse to begin to assign to the licensed practical nurse - ANSWER A bedfast client who needs daily irrigation of a stage 4 pressure ulcer. A 65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed by the healthcare provider. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided. What is the legal status of the nurse? - ANSWER The client would not be able to prove malpractice in court. In completing the treatment plan for an 11-year-old who has bipolar disorder, the nurse plans outcomes for the nursing diagnosis, "Risk for violence towards peers related to impulsivity."Which outcome is important? - ANSWER Seeks out staff when having thoughts of harming others. The most important outcome is for the client to seek staff when thoughts of harming others occur. The nurse is teaching a childbirth education class t prospective parents and describing possible signs of labor. Class participants should be taught that which sign should be reported to the healthcare provider immediately? - ANSWER Leaking of fluid from the vagina The nurse is performing a surgical hand scrub prior to entering the operating room. In what order should the nurse perform the steps of this procedure? - ANSWER Scrape under the nails with a nail pick. Rinse from the fingertips to the elbow. Use a soapy brush to scrub the hands. Cleanse the arm with a lathered brush How to do surgical scrubbing - ANSWER clean nails, then hands, than arm, than u rinse the whole thing off starting from fingertips to upper arm An elderly client is admitted with a diagnosis of pneumonia. What sign or symptom would require immediate intervention by the nurse? - ANSWER Has become agitated, aggressive and confused. A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? - ANSWER Assist the client to sharply flex her thighs up against the abdomen. While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. What action should the nurse implement next? - ANSWER Answer: Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading. A 6-month-old male with bronchiolitis is admitted to the hospital. I monitoring the respiratory status of the child, which symptom indicates to the nurse that he is experiencing respiratory distress? - ANSWER Respiratory rate of 62 breaths/minute Child w/ scabies what would u do to prevent complication - ANSWER cut the nails and put mitten on The healthcare provider prescribes oxytocin synthetic (Pitocin), 10 units/L via IV drip to augment a client's labor because she is experiencing a prolonged active phase. Because the client is receiving Pitocin, the nurse should closely monitor for which complication? - ANSWER Uterine Tetany Hepatic encephalopathy - ANSWER Ammonia. A client with a deep vein thrombosis is receiving a heparin protocol based on a target partial thromboplastin time (PPT) of 65 to 95 seconds. The client's current PTT result is 35 seconds. What action should the nurse implement? - ANSWER Increasing the rate of the heparin infusion. Female pt who being sexually and physically abused by bf and states I cant take it anymore - ANSWER ask her if she is thinking about suicide A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement? - ANSWER Reschedule administration of the antibiotic until after he completes his prayers Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother's vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first? - ANSWER Perform fundal massage until firm