HESI 4 ran exit 366 Questions With Complete Solutions
347. After receiving report, the nurse can most safely plan to
assess which client last? The client with... Correct Answers No
postoperative drainage in the Jackson-Pratt drain with the bulb
compressed.
Rationale: The most stable client is the one with a functioning
drainage device and no drainage. This client can most safely be
assesses last. Other clients are either actively bleeding, have an
obstruction in the nasogastric tube which may result in vomiting,
or may be bleeding and / or may have a malfunction in the
Hemovac® drain.
348. The nurse instructs an unlicensed assistive personnel
(UAP) to turn an immobilized elderly client with an indwelling
urinary catheter every two hours. What additional action should
the nurse instruct the UAP to take each time the client is turned?
Correct Answers Offer the client oral fluids.
Rationale: Increasing oral fluid intake reduces the risk of
problems associated with immobility, so the UAP should be
instructed to offer the client oral fluids every two hours, or
whenever turning he client. It is not necessary to empty the
urinary bag or feed the client every two hours. Assessment is a
nursing function, and UAPs do not have the expertise to perform
assessment of breath sounds.
,349. The nurse is preparing a client who had a below-the-knee
(BKA) amputation for discharge to home. Which
recommendations should the nurse provide this client? (Select
all that apply) Correct Answers Inspect skin for redness.
Use a residual limb shrinker.
Wash the stump with soap and water.
Rationale: Several actions are recommended for home care
following an amputation. The skin should be inspected regularly
for abnormalities such as redness, blistering, or abrasions. A
residual limb shrinker should be applied over the stump to
protect it and reduce edema. The stump should be washed daily
with a mild soap and carefully rinse and dried. The client should
avoid cleansing with alcohol because it can dry and crack the
skin. Range of motion should be done daily.
350. When assessing the surgical dressing of a client who had
abdominal surgery the previous day, the nurse observes that a
small amount of drainage is present on the dressing and the
wound's Hemovac suction device is empty with the plug open.
How should the nurse respond? Correct Answers Recompress
the wound suction device and secure to plug.
Rationale: The plug of a wound suction device, such as a
Hemovac, should be closed after compressing the device to
apply gentle suction in a closed surgical wound to facilitate the
evacuation of subcutaneous fluids into the device. Compressing
the device and securing the plug should restore function of the
,closed wound device. A small amount of drainage should be
marked on the dressing, but replacing the dressing is not
necessary and the nurse should not remove the device. Other
options are not indicated.
351. A mother brings her 4-month-old son to the clinic with a
quarter taped over his umbilicus, and tells the nurse the quarter
is supposed to fix her child's hernia. Which explanations should
the nurse provide? Correct Answers This hernia is a normal
variation that resolves without treatment.
Rational: an umbilical hernia is a normal variation in infants that
occurs due to an incomplete fusion of the abdominal
musculature through the umbilical ring that usually resolves
spontaneously as the child learns to walk. Other choices are
ineffective and unnecessary.
352. A client who is admitted to the intensive care unit with
syndrome of inappropriate antidiuretic hormone (SIADH) has
developed osmotic demyelination. Which intervention should
the nurse implement first? Correct Answers Evaluate swallow.
Rational: Osmotic demyelination, also known as central pontine
myelinolysis, is nerve damage caused by the destruction of the
myelin sheath covering nerve cells in the brainstem. The most
common cause is a rapid, drastic change in sodium levels when
a client is being treated for hyponatremia, a common occurrence
in SIADH. Difficulty swallowing due to brainstem nerve
, damage should be care, but determining the client's risk for
aspiration is most important.
353. A client with possible acute kidney injury (AKI) is
admitted to the hospital and mannitol is prescribed as a fluid
challenge. Prior to carrying out this prescription, what
intervention should the nurse implement? Correct Answers
Obtain vital signs and breath sounds.
Rational: the client's baseline cardiovascular status should be
determined before conducting the fluid challenge. If the client
manifests changes in the vital signs and breath sounds associated
with pulmonary edema, the administration of the fluid challenge
should be terminate. Other options would not assure a safe
administration of the medication.
301. If the nurse is initiating IV fluid replacement for a child
who has dry, sticky mucous membranes, flushed skin, and fever
of 103.6 F. Laboratory finding indicate that the child has a
sodium concentration of 156 mEq/L. What physiologic
mechanism contributes to this finding? Correct Answers
Insensible loss of body fluids contributes to the
hemoconcentration of serum solutes.
Rationale: Fever causes insensible fluid loss, which contribute to
fluid volume and results in hemoconcentration of sodium (serum
sodium greater than 150 mEq/L). Dehydration, which is
manifested by dry, sticky mucous membranes, and flushed skin,
347. After receiving report, the nurse can most safely plan to
assess which client last? The client with... Correct Answers No
postoperative drainage in the Jackson-Pratt drain with the bulb
compressed.
Rationale: The most stable client is the one with a functioning
drainage device and no drainage. This client can most safely be
assesses last. Other clients are either actively bleeding, have an
obstruction in the nasogastric tube which may result in vomiting,
or may be bleeding and / or may have a malfunction in the
Hemovac® drain.
348. The nurse instructs an unlicensed assistive personnel
(UAP) to turn an immobilized elderly client with an indwelling
urinary catheter every two hours. What additional action should
the nurse instruct the UAP to take each time the client is turned?
Correct Answers Offer the client oral fluids.
Rationale: Increasing oral fluid intake reduces the risk of
problems associated with immobility, so the UAP should be
instructed to offer the client oral fluids every two hours, or
whenever turning he client. It is not necessary to empty the
urinary bag or feed the client every two hours. Assessment is a
nursing function, and UAPs do not have the expertise to perform
assessment of breath sounds.
,349. The nurse is preparing a client who had a below-the-knee
(BKA) amputation for discharge to home. Which
recommendations should the nurse provide this client? (Select
all that apply) Correct Answers Inspect skin for redness.
Use a residual limb shrinker.
Wash the stump with soap and water.
Rationale: Several actions are recommended for home care
following an amputation. The skin should be inspected regularly
for abnormalities such as redness, blistering, or abrasions. A
residual limb shrinker should be applied over the stump to
protect it and reduce edema. The stump should be washed daily
with a mild soap and carefully rinse and dried. The client should
avoid cleansing with alcohol because it can dry and crack the
skin. Range of motion should be done daily.
350. When assessing the surgical dressing of a client who had
abdominal surgery the previous day, the nurse observes that a
small amount of drainage is present on the dressing and the
wound's Hemovac suction device is empty with the plug open.
How should the nurse respond? Correct Answers Recompress
the wound suction device and secure to plug.
Rationale: The plug of a wound suction device, such as a
Hemovac, should be closed after compressing the device to
apply gentle suction in a closed surgical wound to facilitate the
evacuation of subcutaneous fluids into the device. Compressing
the device and securing the plug should restore function of the
,closed wound device. A small amount of drainage should be
marked on the dressing, but replacing the dressing is not
necessary and the nurse should not remove the device. Other
options are not indicated.
351. A mother brings her 4-month-old son to the clinic with a
quarter taped over his umbilicus, and tells the nurse the quarter
is supposed to fix her child's hernia. Which explanations should
the nurse provide? Correct Answers This hernia is a normal
variation that resolves without treatment.
Rational: an umbilical hernia is a normal variation in infants that
occurs due to an incomplete fusion of the abdominal
musculature through the umbilical ring that usually resolves
spontaneously as the child learns to walk. Other choices are
ineffective and unnecessary.
352. A client who is admitted to the intensive care unit with
syndrome of inappropriate antidiuretic hormone (SIADH) has
developed osmotic demyelination. Which intervention should
the nurse implement first? Correct Answers Evaluate swallow.
Rational: Osmotic demyelination, also known as central pontine
myelinolysis, is nerve damage caused by the destruction of the
myelin sheath covering nerve cells in the brainstem. The most
common cause is a rapid, drastic change in sodium levels when
a client is being treated for hyponatremia, a common occurrence
in SIADH. Difficulty swallowing due to brainstem nerve
, damage should be care, but determining the client's risk for
aspiration is most important.
353. A client with possible acute kidney injury (AKI) is
admitted to the hospital and mannitol is prescribed as a fluid
challenge. Prior to carrying out this prescription, what
intervention should the nurse implement? Correct Answers
Obtain vital signs and breath sounds.
Rational: the client's baseline cardiovascular status should be
determined before conducting the fluid challenge. If the client
manifests changes in the vital signs and breath sounds associated
with pulmonary edema, the administration of the fluid challenge
should be terminate. Other options would not assure a safe
administration of the medication.
301. If the nurse is initiating IV fluid replacement for a child
who has dry, sticky mucous membranes, flushed skin, and fever
of 103.6 F. Laboratory finding indicate that the child has a
sodium concentration of 156 mEq/L. What physiologic
mechanism contributes to this finding? Correct Answers
Insensible loss of body fluids contributes to the
hemoconcentration of serum solutes.
Rationale: Fever causes insensible fluid loss, which contribute to
fluid volume and results in hemoconcentration of sodium (serum
sodium greater than 150 mEq/L). Dehydration, which is
manifested by dry, sticky mucous membranes, and flushed skin,
