2O23 HESI EXIT TEST BANK V1
QUESTIONS AND 100%
CORRECT ANSWERS A GRADE LATEST
UPDATE EXAM
While assessing a radial artery catheter, the client complains of numbness and pain
distal to the insertion site. What interventions should the nurse implement? --
CORRECT 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 vascular source of the intracranial bleeding, which finding
should the nurse monitor? -- CORRECT 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? -- CORRECT 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? -- CORRECT 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? -- CORRECT 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? -- CORRECT ANSWER-Diminished left 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) -- CORRECT ANSWER-Arterial endothelium injury causes
inflammation
Macrophages consume low density lipoprotein (LDL), creating foam cells
Foam cells release growth factors for smooth muscle cells
,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? --
CORRECT ANSWER-Oliguria signals tubular necrosis related to hypoperfusion
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing
formula based on what data ensures quality client care and is most cost-effective? --
CORRECT 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? -- CORRECT 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? -- CORRECT 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's return demonstration, which action indicated that the client understood the
teaching? -- CORRECT ANSWER-Keeps the irrigating container less than 18 inches
above the stoma
The nurse should teach the client to observe which precaution while taking
dronedarone? -- CORRECT ANSWER-Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is admitted to the
hospital. The nurse include the client's risk for developing increased intracranial
pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has
increased? -- CORRECT ANSWER-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of increased ICP, and confusion is usually
the first sign of
increased ICP. Other options do not necessarily reflect increased ICP.
QUESTIONS AND 100%
CORRECT ANSWERS A GRADE LATEST
UPDATE EXAM
While assessing a radial artery catheter, the client complains of numbness and pain
distal to the insertion site. What interventions should the nurse implement? --
CORRECT 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 vascular source of the intracranial bleeding, which finding
should the nurse monitor? -- CORRECT 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? -- CORRECT 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? -- CORRECT 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? -- CORRECT 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? -- CORRECT ANSWER-Diminished left 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) -- CORRECT ANSWER-Arterial endothelium injury causes
inflammation
Macrophages consume low density lipoprotein (LDL), creating foam cells
Foam cells release growth factors for smooth muscle cells
,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? --
CORRECT ANSWER-Oliguria signals tubular necrosis related to hypoperfusion
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing
formula based on what data ensures quality client care and is most cost-effective? --
CORRECT 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? -- CORRECT 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? -- CORRECT 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's return demonstration, which action indicated that the client understood the
teaching? -- CORRECT ANSWER-Keeps the irrigating container less than 18 inches
above the stoma
The nurse should teach the client to observe which precaution while taking
dronedarone? -- CORRECT ANSWER-Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is admitted to the
hospital. The nurse include the client's risk for developing increased intracranial
pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has
increased? -- CORRECT ANSWER-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of increased ICP, and confusion is usually
the first sign of
increased ICP. Other options do not necessarily reflect increased ICP.
