160 HESI RN EXIT V2 QUESTIONS
AND ANSWERS
Terms in this set (160)
,The nurse assumes care of a postoperative adult client with type 2
diabetes mellitus and learns that the client has a current blood
glucose level of 720 mg/dL. When assessing the client, what is the
priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate
A. Assess for signs of fluid volume deficit
A male client tells the nurse that he is concerned that he may
have a stomach ulcer, because he is experiencing heartburn and
dull gnawing pain that is relieved when he eats. Which is the best
response by the nurse?
A. Encourage the client to obtain a complete physical exam,
since these symptoms are consistent with an ulcer
B. Assure the client that his symptoms may only reflect reflux,
since ulcer pain is not relieved with food
C. Instruct the client that these mild symptoms can generally be
controlled with changes in his diet
,D. Advise the client that he needs to seek immediate medical
evaluation and treatment of these symptoms
A. Encourage the client to obtain a complete physical exam since
these symptoms are consistent with an ulcer
A male client with stomach cancer returns to the unit following a
total gastrectomy. He has a nasogastric tube to suction and is
receiving Lactated Ringer's solution at 75 mL/hr IV. One hour after
admission to the unit, the nurse notes 300mL of blood in the
suction canister, the client's heart rate is 155 beats/minute, and his
blood pressure is 78/48 mmHg. In addition to reporting the
findings to the surgeon, which action should the nurse implement
first?
A. Measure and document the client's urinary output
B. Request the client's reserved unit of packed red blood cells
C. Prepare for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution
D. Increase the infusion rate of Lactated Ringer's solution
, A heparin infusion is prescribed for a client who weighs 220
pounds. After administering a bolus dose of 80 units/kg, the
nurse calculates the infusion rate for the heparin solution as 18
units/kg/hour. The available solution is Heparin Sodium 25,000
Units in 5% Dextrose Injection 250 mL. The nurse should program
the infusion pump to deliver how many mL/hour?
-1st: calculate the weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800
units/hr
- 25000 units - in 250 1800 units
---in X ml x = 1800 x 250/25000
=18 mL/hr
An adult male who fell 20 feet from the roof of his home has
multiple injuries, including a right pneumothorax. Chest tubes
were inserted in the emergency department prior to his transfer to
the intensive care unit (ICU). The nurse notes that the suction
control chamber is bubbling at the -10cm H2O mark, which
AND ANSWERS
Terms in this set (160)
,The nurse assumes care of a postoperative adult client with type 2
diabetes mellitus and learns that the client has a current blood
glucose level of 720 mg/dL. When assessing the client, what is the
priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate
A. Assess for signs of fluid volume deficit
A male client tells the nurse that he is concerned that he may
have a stomach ulcer, because he is experiencing heartburn and
dull gnawing pain that is relieved when he eats. Which is the best
response by the nurse?
A. Encourage the client to obtain a complete physical exam,
since these symptoms are consistent with an ulcer
B. Assure the client that his symptoms may only reflect reflux,
since ulcer pain is not relieved with food
C. Instruct the client that these mild symptoms can generally be
controlled with changes in his diet
,D. Advise the client that he needs to seek immediate medical
evaluation and treatment of these symptoms
A. Encourage the client to obtain a complete physical exam since
these symptoms are consistent with an ulcer
A male client with stomach cancer returns to the unit following a
total gastrectomy. He has a nasogastric tube to suction and is
receiving Lactated Ringer's solution at 75 mL/hr IV. One hour after
admission to the unit, the nurse notes 300mL of blood in the
suction canister, the client's heart rate is 155 beats/minute, and his
blood pressure is 78/48 mmHg. In addition to reporting the
findings to the surgeon, which action should the nurse implement
first?
A. Measure and document the client's urinary output
B. Request the client's reserved unit of packed red blood cells
C. Prepare for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution
D. Increase the infusion rate of Lactated Ringer's solution
, A heparin infusion is prescribed for a client who weighs 220
pounds. After administering a bolus dose of 80 units/kg, the
nurse calculates the infusion rate for the heparin solution as 18
units/kg/hour. The available solution is Heparin Sodium 25,000
Units in 5% Dextrose Injection 250 mL. The nurse should program
the infusion pump to deliver how many mL/hour?
-1st: calculate the weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800
units/hr
- 25000 units - in 250 1800 units
---in X ml x = 1800 x 250/25000
=18 mL/hr
An adult male who fell 20 feet from the roof of his home has
multiple injuries, including a right pneumothorax. Chest tubes
were inserted in the emergency department prior to his transfer to
the intensive care unit (ICU). The nurse notes that the suction
control chamber is bubbling at the -10cm H2O mark, which
