RN EXIT HESI EXAM V5 WITH CORRECT ANSWERS

RN EXIT HESI EXAM V5 WITH CORRECT ANSWERS




After placing a 36-week gestation newborn in and isolette and drying the infant with several blankets, what
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should the nurse implement next? t t t t




a. Administer the vitamin K injection
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b. Remove the wet blankets and linens from the isolette
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c. Place erythromycin ophthalmic ointment in both eyes
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d. Open the isolate door to assess the infants' vital signs - correct answer c. Place erythromycin ophthalmic
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ointment in both eyes t t t




A client in the third trimester of pregnancy complaints of frequent nasal stuffiness and occasional nosebleeds.
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Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her
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diaphragm is elevated, and she has an increased costal angle. Which intervention should the nurse
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implement?

A. Ask a nurse with more experience to validate the costal angle finding
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B. Ask the health care provider to evaluate the client's respiratory status
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C. Examine the client for signs of tissue and anoxia, such as pallor
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D. Record the respiratory finding in the client's record as normal - correct answer C. Examine the client for signs
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of tissue and anoxia, such as pallor
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A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings. His
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appetite is poor, and he often uses oral intake of solids and liquids. For the past several days he has been unable
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to get out of bed. Which action should the hospice nurse implement?
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A. Ask family to remain nearby, but in another room
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B. Encourage family to speak often with the client
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C. Teach family how to assist the client to a wheelchair
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D. Instruct family to offer client only soft bland foods - correct answer C. Teach family how to assist the client to
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a wheelchair
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,A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy tests and
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ultrasounds were negative, so an exploratory laparotomy was completed during the night. When coffee t t t t t t t t t t t t t t




ground material is observed in the drainage from the nasal gastric tube, which intervention should the nurse
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implement?

a. Verify correct placement of the nasogastric tube
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b. Perform gastroccult test on the nasogastric drainage
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c. Listen for evidence of diminished bowel sounds
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d. Irrigate the nasogastric tube with water until clear - correct answer a. Verify correct placement of the
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nasogastric tube t




The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports that the
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abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to
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evaluate the client's clinical recovery? t t t t




a. Lipaset




b. Creatininet




c. Bilirubin
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d. Glucose - correct answer a. Lipase
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While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL of dark red fluid
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has drained from the nasogastric tube in the last hour. Which action should the nurse take first?
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a. Determine the client's vital signs
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b. Monitor urinary output hourly
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c. Notify the surgeon immediately
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d. Assess the client's level of pain - correct answer b. Monitor urinary output hourly
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The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and
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emphysema. Which healthcare measure is most important for the nurse to recommend to these clients? t t t t t t t t t t t t t t




a. Ensure supplemental oxygen and respiratory medications are available at all times
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b. Use nasal or cough tissues followed by hand washing at all times
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c. Get annual flu and pneumococcal vaccine polyvalent vaccines
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,d. Avoid large crowded areas during the colder months of the year - correct answer d. Avoid large crowded
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areas during the colder months of the year
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A mother of a one-month-old infant calls the clinic to report that the back of her infant's head is flat. How
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should the nurse respond? t t t




a. Position the infant on the stomach occasionally when awake and active
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b. Turn the infant on the left side braced against the crib when sleeping
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c. Prop the infant in a sitting position with a cushion when not sleeping
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d. Place a small pillow under the infants head while lying on the back - correct answer a. Position the infant on
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the stomach occasionally when awake and active
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A woman is brought to the labor and delivery unit after delivering a term infant and the placenta in the hospital
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parking lot 10 minutes ago. Which action should the nurse perform first?
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a. Inspect the perineum for lacerations
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b. Collect specimen for hemoglobin and hematocrit
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c. Massage the fundus and give oxytocic agent
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d. Place the infant to breast for bonding - correct answer c. Massage the fundus and give oxytocic agent
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A client has a new prescription for the maximum recommended dosage of piperacillin/tazobactam for
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nosocomial pneumonia. The nurse should report which laboratory finding to the health care provider before t t t t t t t t t t t t t t t




administering the prescribed dose? t t t




a. Elevated white blood cell count
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b. Presence of gram-positive bacteria in the sputum
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c. Decrease creatinine clearance
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d. Elevated cholesterol and lipoproteins - correct answer b. Presence of gram-positive bacteria in the sputum
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A client who is admitted with diabetic ketoacidosis is demonstrating Kussmaul breathing and has a severe
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headache along with nausea. Her arterial blood gases are: ph 7.50; paco2 30 mmhg; HCO3 24 meq/L. Which
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assessment finding warrants immediate intervention by the nurse? t t t t t t t




a. Muscle stiffness
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b. Abdominal pain
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c. Mental stupor
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, d. Fruity breath - correct answer d. Fruity breath
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When performing postural drainage on a client with chronic obstructive pulmonary disease, which approach
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should the nurse use? t t t




a. Explain that the client may be placed in five positions
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b. Instruct the client to breathe shallow and fast
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c. Obtain arterial blood gases prior to the procedure
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d. Perform the drainage immediately after meals - correct answer a. Explain that the client may be placed in
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five positions t




A young male client with testicular cancer has a living will that describes his desire that no extraordinary
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measures be taken to save his life. The health care provider knows the client has a good prognosis and refuses t t t t t t t t t t t t t t t t t t t t




to write a "do not resuscitate" (DNR) prescription. Which action should the nurse take?
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A. Initiate an Ethics Committee review of the case
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B. Place a DNR bracelet on the client's arm
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C. Ensure resuscitation equipment is available
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D. Ask the family to review options with the client - correct answer A. Initiate an Ethics Committee review of the
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case



In observing a client's face, which assessment finding requires the most immediate intervention by the nurse?
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a. Cornea are jaundiced
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b. Oral mucosa is cyanotic
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c. Face is flushed and diaphoretic
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d. Eyelids are matted and crusted - correct answer b. Oral mucosa is cyanotic
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The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which
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action should the nurse take in response to the finding?
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a. Ask the client to describe recent alcohol use
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b. Keep the clients feet elevated when in bed
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c. Assess the clients muscle strength and tone
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