STUDOC : Hesi Exit RN V3 questions and Answers

STUDOC : Hesi Exit RN V3 questions
and Answers

61-Anyolderyclientyisyadmittedyforyrepairyofyaybrokenyhip.yToyreduceytheyriskyforyinfection
inytheypostoperativeyperiod,ywhichynursingycareyinterventionsyshouldytheynurseyincludeyinyt
he
client'syplanyofycare?y(Selectyallythatyapply)
A)yTeachyclientytoyuseyincentiveyspirometeryq2yhoursywhileyawake
B)yRemoveyurinaryycatheteryasysoonyasypossibleyandyencourageyvoiding
C)yMaintainysequentialycompressionydevicesywhileyinybed
D)yAdministerylowymolecularyweightyheparinyasyprescribed
E)yAssessypainylevelyandymedicateyPRNyasyprescribedy-yCORRECTyyANSWER-
A)yTeachyclientytoyuseyincentiveyspirometeryq2yhoursywhileyawake
B)yRemoveyurinaryycatheteryasysoonyasypossibleyandyencourageyvoiding

Ay14yyear-oldywithyayhistoryyofysickleycellydiseaseyisyadmittedytoytheyhospitalywithya
diagnosisyofyvaso-occlusiveycrisis.yWhichystatementsybyytheyclientywouldybeymost
indicativeyofytheyetiologyyofythisycrisis?
A)y"Iyknewythisywouldyhappen.yI'veybeenyeatingytooymuchyredymeatylately."
B)y"Iyreallyyenjoyedymyyfishingytripyyesterday.yIycaughty2yfish."
C)y"Iyhaveyreallyybeenyworkingyhardypracticingywithytheydebateyteamyatyschool."
D)"IywentytoytheyhealthycareyproviderylastyweekyforyaycoldyandyIyhaveygottenyworse."y-
yCORRECTyyANSWER-

D)"IywentytoytheyhealthycareyproviderylastyweekyforyaycoldyandyIyhaveygottenyworse."

Ay15-year-
oldymaleyclientywasyrecentlyydiagnosedywithytypey1ydiabetesymellitus.yHeytellsythe
nurseythatyheyisyhavingydifficultyyadheringytoyhisymealyplanywhenyheyisywithyhisyfriends.yWh
at
nursingyinterventionyisybestyforytheynurseytoyimplement?
a.yRecommendyheyavoidyfastyfoodyrestaurantsyuntilyheyisyfamiliarywithyhisyprescribedydiet.
b.yAdviseyhimytoytakeyhisyownyfoodywithyhimywhenygoingytoyfastyfoodyrestaurantsywithyhis
friends.
c.yEncourageyhimytoyfindyactivitiesytoydoywithyhisyfriendsythatydoynotyinvolveyeating.
d.yAssistyhimyinyidentifyingypopularyfastyfoodsythatyareywithinyhisymealyplanyforydiabetes.y-
yCORRECTyyANSWER-

d.yAssistyhimyinyidentifyingypopularyfastyfoodsythatyareywithinyhisymealyplanyforydiabetes.

Ay20yyear-oldyclientyhasyanyinfectedylegywoundyfromyaymotorcycleyaccident,yandythe
clientyhasyreturnedyhomeyfromytheyhospital.yTheyclientyisytoykeepytheyaffectedylegyelevated
andyisyonycontactyprecautions.yTheyclientywantsytoyknowyifyvisitorsycanycome.yTheyappropr
iateyresponse

,fromytheyhomeyhealthynurseyisythat:
A)yVisitorsymustywearyaymaskyandyaygown
B)yThereyareynoyspecialyrequirementsyforyvisitorsyofyclientsyonycontactyprecautions
C)yVisitorsyshouldywashytheiryhandsybeforeyandyafterytouchingytheyclient
D)yVisitorsyshouldywearyglovesyifytheyytouchytheyclienty-yCORRECTyyANSWER-
C)yVisitorsyshouldywashytheiryhandsybeforeyandyafterytouchingytheyclient

Ay4yyear-oldyhasybeenyhospitalizedyfory24yhoursywithyskeletalytractionyforytreatmentyof
ayfractureyofytheyrightyfemur.yTheynurseyfindsythatytheychildyisynowycryingyandytheyright
footyisypaleywithytheyabsenceyofyaypulse.yWhatyshouldytheynurseydoyfirst?
A)yNotifyytheyhealthycareyprovider
B)yReadjustytheytraction
C)yAdministerytheyorderedyPRNymedication
D)yReassessytheyfootyinyfifteenyminutesy-yCORRECTyyANSWER-
A)yNotifyytheyhealthycareyprovider

Ay60yyear-oldymaleyclientyhadyayherniayrepairyinyanyoutpatientysurgeryyclinic.yHeyis
awakeyandyalert,ybutyhasynotybeenyableytoyvoidysinceyheyreturnedyfromysurgeryy6yhoursyag
o.
Heyreceivedy1000ymLyofyIVyfluid.yWhichyactionywouldybeymostylikelyytoyhelpyhimyvoid?
A)yHaveyhimydrinkyseveralyglassesyofywater
B)yCrede'ytheybladderyfromytheybottomytoytheytop
C)yAssistyhimytoystandybyytheysideyofytheybedytoyvoid
D)yWaity2yhoursyandyhaveyhimytryytoyvoidyagainy-yCORRECTyyANSWER-
C)yAssistyhimytoystandybyytheysideyofytheybedytoyvoid

Aychildyisyadmittedytoytheypediatricyunitywithyaydiagnosisyofysuspectedymeningococcal
meningitis.yWhichyadmissionyordersyshouldytheynurseydoyfirst?
A)yInstituteyseizureyprecautions
B)yMonitoryneurologicystatusyeveryyhour
C)yPlaceyinyrespiratory/secretionyprecautions
D)yCefotaximeyIVy50ymg/kg/dayydividedyq6hy-yCORRECTyyANSWER-
C)yPlaceyinyrespiratory/secretionyprecautions

Ayclientyadmittedywithyayliveryabscessyisyscheduledyforysurgicalyevacuationyandydrainagey
ofythe
abscessytomorrowymorning.yNursingyassessy....yClient'syabdominalypainyhasyincreasedyfr
omy4ytoy8
onyay10-pointyscaleyinytheylastyfouryhours.yWhatyisypriorityynursingyaction?
a.yNotifyytheysurgeonyofyincreasingyabdominalypain.
b.yAdministerytheynestyscheduledydoseyofyantibiotic.
c.yEncourageytheyclientytoycoughyandydeepybreath.
d.yAssessyforyaychangeyinytheyclient'sybowelysoundsy-yCORRECTyyANSWER-
a.yNotifyytheysurgeonyofyincreasingyabdominalypain.

,Ayclientyarrivesyforyanyannualyphysicalyexamyandycomplainsyofyhavingycalfypain.yTheyclient
'syhealth
historyyrevealsyperipheralyatrialydisease.yWhichyquestionyshouldytheynurseyaskytheyclientya
bout
expectedyfindingyrelatedytoychronicyarterialysymptoms?
a.yWereyyourylegsyeverysuddenlyyswollen,yred,ywarm,yandypainful?
b.yDoesytheycalfypainyoccurywhenywalkingyshortydistances?
c.yDidyyouyreceiveytreatmentyforyweepingyulcersyonylowerylegs?
d.yHaveyyouyexperiencedyankleyedemayandyvaricoseyveinsy-yCORRECTyyANSWER-
b.yDoesytheycalfypainyoccurywhenywalkingyshortydistances?

AyclientydiagnosedywithycirrhosisyofytheyliveryandyascitesyisyreceivingySpironolactone
(Aldactone).yTheynurseyunderstandsythatythisymedicationysparesyeliminationyofywhich
element?
A)ySodium
B)yPotassium
C)yPhosphate
D)yAlbuminy-yCORRECTyyANSWER-B)yPotassium

Ayclientyhasyaychestytubeyinyplaceyfollowingyayleftylowerylobectomyyinsertedyafteryaystab
woundytoytheychest.yWhenyrepositioningytheyclient,ytheynurseynoticesy200yccyofydark,yred
fluidyflowsyintoytheycollectionychamberyofytheychestydrain.yWhatyisytheymostyappropriate
nursingyaction?
A)yClampytheychestytube
B)yCallytheysurgeonyimmediately
C)yPrepareyforybloodytransfusion
D)yContinueytoymonitorytheyrateyofydrainagey-yCORRECTyyANSWER-
D)yContinueytoymonitorytheyrateyofydrainage

Ayclientyhasyayhistoryyofychronicyobstructiveypulmonaryydiseasey(COPD).yAsytheynurse
entersytheyclient'syroom,yhisyoxygenyisyrunningyaty6ylitersyperyminute,yhisycoloryisyflushed
andyhisyrespirationsyarey8yperyminute.yWhatyshouldytheynurseydoyfirst?
A)yObtainyay12-leadyEKG
B)yPlaceyclientyinyhighyFowler'syposition
C)yLowerytheyoxygenyrate
D)yTakeybaselineyvitalysignsy-yCORRECTyyANSWER-C)yLowerytheyoxygenyrate

Ayclientyhasyalteredyrenalyfunctionyandyisybeingytreatedyatyhome.yTheynurseyrecognizes
thatytheymostyaccurateyindicatoryofyfluidybalanceyduringytheyweeklyyvisitsyis
a.yDifferenceyinytheyintakeyandyoutput
b.yChangesyinytheymucousymembranes
c.ySkinyturgor
d.yWeeklyyweighty-yCORRECTyyANSWER-d.yWeeklyyweight

Ayclientyhasyanyindwellingycatheterywithycontinuousybladderyirrigationyafter
undergoingyaytransurethralyresectionyofytheyprostatey(TURP)y12yhoursyago.yWhichyfinding

, atythisytimeyshouldybeyreportedytoytheyhealthycareyprovider?
A)yLight,ypinkyurine
B)yoccasionalysuprapubicycramping
C)yminimalydrainageyintoytheyurinaryycollectionybag
D)ycomplaintsyofytheyfeelingyofypullingyonytheyurinaryycathetery-yCORRECTyyANSWER-
C)yminimalydrainageyintoytheyurinaryycollectionybag

AyclientyhasybeenydiagnosedywithyZollinger-Ellisonysyndrome.Whichyinformationyis
mostyimportantyforytheynurseytoyreinforceywithytheyclient?
a.yItyisyayconditionyinywhichyoneyorymoreytumorsycalledygastrinomasyformyinytheypancreasy
oryinythe
upperypartyofytheysmallyintestiney(duodenum)
b.yItyisycriticalytoyreportypromptlyytoyyouryhealthycareyprovideryanyyfindingsyofypepticyulcers
c.yTreatmentyconsistsyofymedicationsytoyreduceyacidyandyhealyanyypepticyulcersyand,yifypo
ssible,
surgeryytoyremoveyanyytumors
d.yWithytheyaverageyageyatydiagnosisyaty50yyearsytheypepticyulcersymayyoccuryatyunusualy
areasyofythe
stomachyoryintestiney-yCORRECTyyANSWER-
b.yItyisycriticalytoyreportypromptlyytoyyouryhealthycareyprovideryanyyfindingsyofypepticyulcers

Ayclientyhasyreceivedy2yunitsyofywholeybloodytodayyfollowingyanyepisodeyofyGI
bleeding.yWhichyofytheyfollowingylaboratoryyreportsywouldytheynurseymonitorymost
closely?
A)yBleedingytime
B)yHemoglobinyandyhematocrit
C)yWhiteybloodycells
D)yPlateletsy-yCORRECTyyANSWER-B)yHemoglobinyandyhematocrit

Ayclientyhasyreturnedyfromyaycardiacycatheterization.yWhichyoneyofytheyfollowing
assessmentsywouldyindicateytheyclientyisyexperiencingyaycomplicationyfromytheyprocedure
?
A)yIncreasedybloodypressure
B)yIncreasedyheartyrate
C)yLossyofypulseyinytheyextremity
D)yDecreasedyurineyoutputy-yCORRECTyyANSWER-C)yLossyofypulseyinytheyextremity

Ayclientyhasyviralypneumoniayaffectingy2/3yofytheyrightylung.yWhatywouldybeytheybest
positionytoyteachytheyclientytoylieyinyeveryyotheryhouryduringyfirsty12yhoursyafteryadmission?
A)ySide-lyingyonytheyleftywithytheyheadyelevatedy10ydegrees
B)ySide-lyingyonytheyleftywithytheyheadyelevatedy35ydegrees
C)ySide-lyingyonytheyrightywithytheyheadyelevatedy10ydegrees
D)ySide-lyingyonytheyrightywithytheyheadyelevatedy35ydegreey-yCORRECTyyANSWER-
A)ySide-lyingyonytheyleftywithytheyheadyelevatedy10ydegrees

Ayclientyisyadmittedyforyfirstyandysecondydegreeyburnsyonytheyface,yneck,yanteriorychest