Exit Hesi (BSN 366) (Latest Update )
Questions and Verified Answers | 100% Correct |
Grade A - Nightingale
The healthcare provider prescribes methylergonovine maleate for a postpartum
client with uterine atony. What findings should indicate to the nurse to withhold
the next dose of the medication?
A. Excessive lochia.
B. Saturation of more than one pad per hour.
C. Hypertension.
D. Difficulty locating the uterine fundus. - ~ ANSWER ~ Answer
C. Hypertension.
Rationale
Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can
exaggerate primary hypertension. The nurse should withhold the medication if the
client's blood pressure is elevated (C) and notify the healthcare provider. (A, B,
and D) are signs of uterine atony and are indications for the use of the medication.
,The nurse has completed the diet teaching of a male client who is being
discharged following treatment of a leg wound. A high protein diet is encouraged
to promote wound healing. Which lunch choice by the client indicates that the
teaching was effective?
A. A peanut butter sandwich with soda and cookies.
B. A tunafish sandwich with chips and ice cream.
C. A salad with three kinds of lettuce and fruit.
D. Vegetable soup, crackers, and milk. - ~ ANSWER ~ Answer
B. A tunafish sandwich with chips and ice cream.
Rationale
(B) contains the highest amount of protein. Four ounces of tuna contains 11 g of
protein, and ice cream 5 g of protein per cup. Chips are a fat with virtually no
protein value. (A) contains 4 grams of protein per tablespoon. (C) contains only 1
gram of protein per 1 cup serving. (D) may have beef flavoring but it consist
mostly of vegetables and would therefore be low in protein.
The nurse discontinues a continuous IV heparin infusion for a male client on strict
bed rest, and is now preparing to administer the client's first dose of in enoxaparin
(Lovenox). Prior to giving this subcutaneous injection, which assessment finding
requires additional intervention by the nurse?
A. Current lab report indicates an aPTT at 1.5 times the client's control.
,B. Several bruised areas are noted on the client's upper extremities bilaterally.
C. The client states that his right calf is aching, and wants pain medication.
D. The spouse is assisting the client who is shaving with an electric razor. - ~
ANSWER ~ Answer
C. The client states that his right calf is aching, and wants pain medication.
Rationale
A calf ache severe enough for the client to request pain medication (C) should be
reported to the healthcare provider immediately so that an adjustment in the
anticoagulation therapy can be made. Calf pain may be a sign of deep vein
thrombosis indicative of ineffective anticoagulant heparin therapy. (A and B) are
expected findings. Shaving with an electric razor is recommended to reduce the
possibility of bleeding (D) and does not require intervention.
While the nurse is providing morning care for a client with chronic obstructive
pulmonary disease (COPD), the client becomes very dyspneic and starts to panic.
What action should the nurse implement first?
A. Instruct the client to perform diaphragmatic breathing.
B. Use a calm voice to tell the client to breathe slowly.
C. Administer two puffs of a metered-dose inhaler.
D. Assist the client to an upright position. - ~ ANSWER ~ Answer
D. Assist the client to an upright position.
, Rationale
The nurse should first assist the client to an upright position (D), which allows the
lungs to expand fully. After this, the nurse can implement (A, B, and C) as needed.
A female client's estranged husband arrives at the hospital and demands that his
wife have no other visitors. The client becomes angry and insists that the
estranged husband be barred from visiting her. Which intervention should the
nurse implement?
A. Obtain a prescription to allow client to dictate who can visit.
B. Request a multidisciplinary care conference to discuss husband's demands.
C. Have the hospital's medical-legal department meet with the client.
D. Encourage the client to speak with husband regarding his disruptive behavior. -
~ ANSWER ~ Answer
B. Request a multidisciplinary care conference to discuss husband's demands.
Rationale
A multi-disciplinary care conference involves the healthcare team to evaluate
difficult situations that conflict with client safety and autonomy. During this
conference, the client's wishes regarding her health care decisions can be clarified
to all team members. All other options are not indicated.
Questions and Verified Answers | 100% Correct |
Grade A - Nightingale
The healthcare provider prescribes methylergonovine maleate for a postpartum
client with uterine atony. What findings should indicate to the nurse to withhold
the next dose of the medication?
A. Excessive lochia.
B. Saturation of more than one pad per hour.
C. Hypertension.
D. Difficulty locating the uterine fundus. - ~ ANSWER ~ Answer
C. Hypertension.
Rationale
Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can
exaggerate primary hypertension. The nurse should withhold the medication if the
client's blood pressure is elevated (C) and notify the healthcare provider. (A, B,
and D) are signs of uterine atony and are indications for the use of the medication.
,The nurse has completed the diet teaching of a male client who is being
discharged following treatment of a leg wound. A high protein diet is encouraged
to promote wound healing. Which lunch choice by the client indicates that the
teaching was effective?
A. A peanut butter sandwich with soda and cookies.
B. A tunafish sandwich with chips and ice cream.
C. A salad with three kinds of lettuce and fruit.
D. Vegetable soup, crackers, and milk. - ~ ANSWER ~ Answer
B. A tunafish sandwich with chips and ice cream.
Rationale
(B) contains the highest amount of protein. Four ounces of tuna contains 11 g of
protein, and ice cream 5 g of protein per cup. Chips are a fat with virtually no
protein value. (A) contains 4 grams of protein per tablespoon. (C) contains only 1
gram of protein per 1 cup serving. (D) may have beef flavoring but it consist
mostly of vegetables and would therefore be low in protein.
The nurse discontinues a continuous IV heparin infusion for a male client on strict
bed rest, and is now preparing to administer the client's first dose of in enoxaparin
(Lovenox). Prior to giving this subcutaneous injection, which assessment finding
requires additional intervention by the nurse?
A. Current lab report indicates an aPTT at 1.5 times the client's control.
,B. Several bruised areas are noted on the client's upper extremities bilaterally.
C. The client states that his right calf is aching, and wants pain medication.
D. The spouse is assisting the client who is shaving with an electric razor. - ~
ANSWER ~ Answer
C. The client states that his right calf is aching, and wants pain medication.
Rationale
A calf ache severe enough for the client to request pain medication (C) should be
reported to the healthcare provider immediately so that an adjustment in the
anticoagulation therapy can be made. Calf pain may be a sign of deep vein
thrombosis indicative of ineffective anticoagulant heparin therapy. (A and B) are
expected findings. Shaving with an electric razor is recommended to reduce the
possibility of bleeding (D) and does not require intervention.
While the nurse is providing morning care for a client with chronic obstructive
pulmonary disease (COPD), the client becomes very dyspneic and starts to panic.
What action should the nurse implement first?
A. Instruct the client to perform diaphragmatic breathing.
B. Use a calm voice to tell the client to breathe slowly.
C. Administer two puffs of a metered-dose inhaler.
D. Assist the client to an upright position. - ~ ANSWER ~ Answer
D. Assist the client to an upright position.
, Rationale
The nurse should first assist the client to an upright position (D), which allows the
lungs to expand fully. After this, the nurse can implement (A, B, and C) as needed.
A female client's estranged husband arrives at the hospital and demands that his
wife have no other visitors. The client becomes angry and insists that the
estranged husband be barred from visiting her. Which intervention should the
nurse implement?
A. Obtain a prescription to allow client to dictate who can visit.
B. Request a multidisciplinary care conference to discuss husband's demands.
C. Have the hospital's medical-legal department meet with the client.
D. Encourage the client to speak with husband regarding his disruptive behavior. -
~ ANSWER ~ Answer
B. Request a multidisciplinary care conference to discuss husband's demands.
Rationale
A multi-disciplinary care conference involves the healthcare team to evaluate
difficult situations that conflict with client safety and autonomy. During this
conference, the client's wishes regarding her health care decisions can be clarified
to all team members. All other options are not indicated.
