NURSING 109 HESI EXIT EXAM PN TEST BANK LATEST UPDATE 2025

1. A male client admitted the morning of his scheduled surgery tells the pn that he drank water last night. What intervention will the pn implement first? Determine the amount of water and exact time it was taken 2. A client receives ondansetron prior to chemotherapy treatment. how should the pn evaluate this medication? Monitor the client for nausea or Vomiting following the treatment 3. The pn is caring for an older adult client who is confused and spends...factor contributes to an increased risk for impaired skin integrity for this client? Has increasing episodes of urinary incontinence 4. The pn determines that a client with cirrhosis is experiencing peripheral take? Protect the clients feet from injury 5. A client is admitted to the postoperative surgical unit after a left lobectomy with two chest tubes observes the water-sealed chambers, set and Prescribed suction of 20cm water what action should the pn implement? Maintain system integrity and to promote lung reexpansion Photo of chest and locating apical hr just below the left nipple 6. At the end of a 12-hour shift the pn observes the urine in a clients drainage. what action should the pn take next? Note the most recent white blood count 7. Thirty minutes after receiving iv morphine, a postoperative male client continue to rate his pain what action should the pn implement first? Implement complementary pain relief methods 8. A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in with one- or two-word responses. The morning the pn observes That he which intervention is most important for the pn to lOMoAR cPSD| implement? Measure appropriate vital signs 9. The pn is assisting a female client to obtain avoided specimen for uri meatus. Which intervention is performed next? Initiate the urine Stream? 10. An 8-year old is placed in 90-90 traction for a fractured femur that resulted from further action bythe pn? weights are touching the foot of the bed 11. The pn is reviewing diet instructions with a female client who has hyper she has increased her intakes of protein and calories. What action Should the pn take? Encourage the client tocontinue the dietary changes she has made 12. The pn reviews the procedure for measuring fluid intake and output...glomerulonephritis and is preparing for discharge from the hospital. What... -why the fluid measurements need to be recoded -which food types are included when measuring fluid take 15. -what container to use for the most accurate measurement request return visit for examination after her period when hormones Are lowest 13. a mother brings her 5-year-old child to the clinic for school physical Examinations. Which assessment... Pn that intergenerational violence may be occurring in thehome? -the 6-year-old son hits his younger sister during the interview -the 10-year-old daughter has circular burns onher trunk and legs 19. -the 3-year-old has multiple bruises on the chest and both legs 14. 20.a client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 ml per houris...1200 the pn notes that there are 750 ml of solution what time should the nurse expect to Discontinue the intravenous therapy? 1700 15. the pn is caring for a client who had a total laryngectomy, left radical neck dissection... Client is receiving nasogastric tube feedings via an internal pump. Today the rate of the feeding was lOMoAR cPSD| increased...ml/hr. What parameter should the pn use to evaluate the clients tolerate to the rate of the feeding? Gastric residual volumes 16. a new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...based on the client complaint, what action should the pn take? Ensure that all the areolar tissue of the nipple is in The infants mouth. 17. Which site should the pn use when administeringan injection of rho (d) immune negative postpartum client? Deltoid Before inserting medication into a clients vagina,what instructions should the pn... Urinate until bladderis empty 18. An 18-year old female client with pelvic inflammatory disease (pid0 asks the pn..which information is best for the pn to provide? A history of untreated gonnorhea can lead to pid 19. a new mother is bottle feeding instead of breastfeeding her newborn, the pn...most effectively deal with breast engorgement and discomfort? Wear A supportive bra at all times 20. a young adult male tells the pn he has declared to change his hours at work so that he can...his community. Which stage of maslow's development is this young adult attempting to achieve? Self-actualiztion 21. a female client arrives to the clinic for an annal physical examination. When reviewing...the pn that she takes herbs for high blood pressure instead of the prescribed..important for the pn to reinforce with the client? Explain Risks associated with using herbs instead of the prescribedantihypertensives. 22. a female native american client who is receiving chemotherapy places a native artifact...the health careprovider removes the medicine wheel and tells the client "this type..hospital" what intervention should thepn implement ? Act as the clients advocate when discussing the issue with the hcp lOMoAR cPSD| 23. the pn is caring for a client receiving chemotherapy who has thrombocytopenia..important to include in the nursing care plan? Watch the client for abnormal bleeding "it is better to obtain children acetaminophen to prevent possible side Effects from the aspirin " 24. a client is transferred to the surgical unit from the intensive care unit after evacuation of bilateral..primary observation should the pn monitor? Neuro-vital signs related to bleeding and intracranial pressure. 25. the pn is working the dayshift in a long term facility and is Preparing..delegate to the uap to perform during the change of..Total The clients po intake, fill the water pitchers, empty urinals and catheter bags..while taking the vital signs of an older male client who takes psychotropic medication...uncontrollable hand movements ad is excessively blinking his eyes, which information screening for tardive dyskinesia 26. a female client tells the pn that her hemorrhoids areinflamed and hurt..the pn to implement to complete a focused assessment? Position client in Left lateral position to inspect perianal area for fissures or sacs 27. the pn is implementing theplan of care for a client who admits Having indicates the highest risk for the client acting on thesesuicidal Thoughts? Begins to show signs of improvement 28. the pn observes that a male clients urinary catheter drainage tubing is the Attached to the bed frame. What action should the pn implement? Observe the appearance of the urine in the drainage tubing 29. a 150 pound adult client with partial-thickness burns over 40% of the body..hospital burn unit. Whichobservation is most important for the pn to report ..........urinary output of 20 ml/hr 30. The pn notes that an elderly client has developed nonproductive the Previous day. Vital signs are temperature 99.8 f; lOMoAR cPSD| pulse 94; respirations 22; and bp important for the pn to implement? Report the findings to the charge Nurse 31. The pn is making shift assignment at an extended care rehabilitation assign To the uap. -toileting assistance for a client receivingtherapy after a total hip replacement -daily skin care for a client with a descending double barrel colostomy -morning care for a clientwith a staph wound infection 32. a client is complaining of a tightening sensation in thefingers, nose tip and ear lobes. pn should be prepared to implement what measure first? Obtain prescribed calcium gluconate for tetany 33. a clients chief complaint is being able to swallow only small bites of solid food pn should assess forwhat additional information? History of alcohol And tobacco use 34. An adult female client with type 1 diabetes mellitus is receiving 35 units of nph insulin pn documentas evidence that the amount of insulin is Inadequate consecutive evening serum glucose readings of >260 mg/dl 46. The pn is assigned the care of four clients on a medical-surgical prioritize Client assessments -a client who is admitted with asuspected ruptured appendix -a client who is post-lumbar puncture is reporting a severeheadache -an older male adult with Alzheimer’s who wanders out of hisroom -a postoperative client who needs reinforcement of discharge instruction 35. following discharge teaching, amale client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? Review with the client the need to avoid foodsthat are rich in milk and cream 36. An adolescent male with severe acne recentlystarted treatment with isotretinoin, a form of vitamin a. During a follow up clinic appointment, which assessment is most important for the pn to complete? lOMoAR cPSD| Ask about occurrence and frequency ofnosebleeds 37. The pn is caring for a client who has silvery scalingplaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to reinforce in this clients plan ofcare? Interventions to decrease emotional stress 38. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at theoutpatient clinic for a scheduled treatment, the client reports increasing fatigue to the the pn, who is taking theclient the clients vital signs. What action should the pn implement ? Reinforce the Need for extra rest periods and plenty of sleep 39. The pn is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue.How should the pn respond? Affirm the importance of rest to promote liver healing 40. When the pn plans daily care for a group pf clients,which client should the pn see first due to the risk of complication?` an older client with a stroke Who is febrile and confused 41. Which foot care instructions is most important forthe pn to reinforce that minimizes a long term complication for a client who is newly diagnosed with type 2 diabetes mellitus (dm)? Report any food injuryor sore that does not readily heal 42. During a clinic visit for a sore throat a clients basal metabolic panel reveals a serum potassium of 3.0bml q/l.Which action should the pn recommend to the client based on this finding? Increase intake of dried peaches and apricots 43. a client with a fractured left hip fracture is in bucks'straction. The pn should expect the client to exhibit which outcome? The left foot is warm to touch with a palpable dorsals pedis pulse 44. When entering the room of an older female resident of a long term care facility, the pn finds one ofthe male residents in bed with her. What action shouldthe pn take? lOMoAR cPSD| Close the door and report the finding to the charge nurse 45. Prior to giving digoxin, the pn assesses that a 2-month-old infants heart rate is 120 beats/min. Based onthis finding what action should the pn take? Give the medication and document the heart rate 46. a resident of a long-term care facility who has a drainage stage 2 pressure. Ulcer receives a prescription for sterile, warm, moist compress q12 hours for 20 minutes to the site. What precautions should the pn take when performing this procedure? Select all that apply -remove soiled dressings with procedure gloved and don sterile glovesfor moist dressing application -place 4x4 gauze sponges on the pressure ulcer andpour warmed water on the dressed site -pour warmed sterile solution to an open steriledressing tray that contained sterile gauze pads 47. a male client who is diagnosed with schizophrenia istaking an antipsychotic medication and calls the psychiatric clinic. The client tell the pn that he is Achy and stiff, has a temperature of 103.4 f and is sweating. How should the pn respond to this client? Direct the client to obtain immediate Transportation to the emergency center 48. a client is diagnosed with with hyperthyroidism. Which symptoms should the pn expect this client to exhibit? Muscle cramping and dry flushed skin pnadministers an antibiotic to a client with a respiratory 49. tract infection...evaluate the medications effectivesnn, which laboratory values should the pn monitor? B,d abd 67. 50. to obtain an estimate of a clients systolic blood pressure, what action should the pn take first? Palpate the clients brachial pulse 51. a client reports feeling numbness and tingling in extremities. What action should the pn implement? Review the clients serum electrolyte levels lOMoAR cPSD| 52. immediately after birth, which nursing interventionhas the highest priority for the newborn infant? Preventing heat loss and neonatal cold stress 53. at 0800 a clients apical pulse rate is 98 beats/minute>four hours later the apical pulse rate is 54 beats/minute.What action should the pn take next? Determine the level of consciousness 54. Which client information is most important for the pn to consider when providing instructions to theuap about providing morning care to a postoperativeclient? Urinary output of 50 ml/hour 55. After report, the pn receives the laboratory valuesfor four clients. Which client requires the pns immediate intervention? A client who is trembling andhas a glucose level of 50 56. Based on the nursing diagnosis of "risk for infection" which intervention should the pn implementwhen providing care for an elderly client with urinary incontinenece maintain standard precautions 57. During recovery after the delivery of a normal infant a client is receiving...ringers 1000 ml with oxytocin 20 units. The pn should evaluate the client forwhich therapeutic response? Stimulation of uterine contractions 58. a 5-year old child is admitted with full thickness burns over 30% of the total body surface areas (tbsa). After fluidreplacement therapy is initiated, Which finding should the pn use to evaluate the effectiveness of the therapy? Urine output 59. the pn enters the room of a client who is disorientedand has a wrist restraint secured as seen in the picturewhat action should the pn take? Photo is of hospital bed and restraint is on the bed frame in a bow tie use a full knot to secure the restraint line 60. a new mother asks the pn about an area of swelling on her baby head that lies across the suture line near the posterior fontanel. How lOMoAR cPSD| should the pn respond? Caput succedaneum will be absorbed and causes no problem 61. the pn obtains a finger stick glucose for a client with type 1 diabetes mellitus who is conscious anddemonstrating hand tremors and shaking. The pn reports the clients result of 55 mg/dl to the nurse. What action should The pn implement next? Provide the client with a glass of milk andcrackers 62. a client who is primigravida at term comes to theprenatal clinic and tells the pn that she is having contractions every 5 minutes. The pn monitors the Client for 1 hour using a external fetal monitor and determines that the clients contractions are 7 to 15minutes apart lasting 20-30 seconds with mild intensity by palpation. What action should the pn take? Send the client home and instruct her to call the clinic when her contractions are 5 minutes apartfor one hour 63. The pn plans to evaluate an adults response to a prescription for colchicine. Last week the client was seenin the clinic for pain in the great left toe, Which was the result of an acute attack of gout. Which data should the pn obtain to evaluate the therapeutic effectiveness of this medication? Pain scale level during walking 64. The pn is caring for a client who was recently diagnosed with hepatitis b virus (hbv). The pn observesthat the clients urine is the color of dark tea. What action should the pn take? Encourage increased oral fluid intake 65. 82.a client develops generalized edema associated withchronic kidney disease (ckd). The pn understands the formation of the edema is the result of Which physiological process? Plasma protein lossesresulting in decreased oncotic pressure within the vessels 66. The pn and uap are providing care for a clientwho exhibits signs of neglect syndrome following astroke affecting the right hemisphere. What action should the pn implement? Demonstrate to the uap how to approach the client from the clients left side lOMoAR cPSD| 67. When assessing an adult male who present at the community health clinic with a history of hypertension the nurse notes that he has 2+ pitting edema in both ankles. He also has a history of gastroesophogeal refluxdisease and depression. Which interventions is most important for the pn to implement? Review the clients use of over the counter (otc) medications 68. a client with alzheimers disease (ad) is receiving trazadone (desyrel) a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the clients mood and sleep patterns are improved but there is no change in cognitive ability. Howshould the nurse respond to this information? Confirm that the desired effect of the medication has been Achieved 69. a client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the pn implement in response to the clients refusal ? Emphasize the importance of active foot flexion 70. a client recovering from a stroke is learning how to usea cane. How should it be placed? on the stronger side of the body 71. a client with schizophrenia is withdrawn isolates himself in the day room and answers questions with oneor two word responses which intervention is most important ? Measure appropriate vital signs 72. while performing the apical pulse of an adult male client the pn notes that the point of maximal impulse is located at the 4th intercostals space medial to the midclavicular line what is the assessment for? Expectedfinding 73. a client with type 2 diabetes becomes unresponsive and says i'm not feeling right which action should the pntake? Give 4 ounces of apple juice 74. a client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug? Provide oral care