HESI 799 RN Exit Exam with |! |! |! |! |! |!
verified solutions |!
A client on a long-term mental health unit repeatedly takes own pulse
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regardless of the circumstance. What action should the nurse implement?
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a. Overlook the client's behavior.
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b. Distract client to interfere with the ritual.
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c. Ask why the client checks the pulse.
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d. Hold client's hand to stop the behavior. - Correct answer ✔Overlook the
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client's behavior. |!
A client is discharged with automated peritoneal dialysis (PD) to be used
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nightly...which instructions should the nurse include? |! |! |! |! |!
a. Wash hands before cleaning exit site
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b. Keep the head of the bed flat at night
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c. Feel for a thrill and a distal pulse nightly
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d. Do not get up if fluid is left in the abdomen - Correct answer ✔Wash
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hands before cleaning exit site
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Rationale: meticulous hand hygiene is essential when performing care for
|! |! |! |! |! |! |! |! |! |!
a peritoneal dialysis, infections is a common complication of peritoneal
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dialysis.
,The charge nurse observes the practical nurse (PN) apply sterile gloves in
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preparation for performing a sterile dressing change. Which action by the
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PN requires correction by the charge nurse?
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a- Opening the package
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b- Picking up the second glove
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c- Picking up the first glove
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d- Positioning of the table - Correct answer ✔Picking up the second glove
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A young adult who is hit with a baseball bat on the temporal area of the
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left skull is conscious when admitted to the ED and is transferred to the
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Neurological Unit to be monitored for signs of closed head injury. Which |! |! |! |! |! |! |! |! |! |! |! |!
assessment finding is indicative of a developing epidural hematoma? |! |! |! |! |! |! |! |!
a. Altered consciousness within the first 24 hours after injury.
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b. Cushing reflex and cerebral edema after 24 hours
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c. Fever, nuchal rigidity and opisthotonos within hours
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d. Headache and pupillary changes 48 hours after a head injury - Correct
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answer ✔Altered consciousness within the first 24 hours after injury.
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A male client reports to the clinic nurse that he has been feeling well and
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
is often "dizzy" his blood pressure is elevated. Based on this findings, this
|! |! |! |! |! |! |! |! |! |! |! |! |!
client is at a greatest risk for which pathophysiological condition?
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a. Pulmonary hypertension
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b. Left ventricular hypertrophy
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,c. Renal failure
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d. Stroke - Correct answer ✔Stroke
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The nurse ask the parent to stay during the examination of a male
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toddler's genital area. Which intervention should the nurse implement?
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a. Examine the genitalia as the last part of the total exam.
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b. Use soothing statements to facilitate cooperation
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c. Allow the child to keep underpants on to examine genitalia
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d. Work slowly and methodically so not to stress the child - Correct answer
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✔Examine the genitalia as the last part of the total exam.
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Rationale: Examination of a child's genitalia is particularly stressful to
|! |! |! |! |! |! |! |! |! |!
toddles, so this assessment is best left as the last part of the examination.
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
B are best done by a parent, not the nurse. The genitals must be
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
completely visualized and sometimes palpates underwear for a brief period
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of.
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The nurse is changing a client's IV tubing and closes the roller clamp on
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the new tubing setup when the bag of solution is _____. Which action
|! |! |! |! |! |! |! |! |! |! |! |! |!
should the nurse take to ensure adequate filling of the drip chamber?
|! |! |! |! |! |! |! |! |! |! |!
a. Lower the IV bag to a flat surface
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b. Compress the drip chamber
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c. Open the roller clamp
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d. Squeeze the bag of IV solution - Correct answer ✔Compress the drip
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chamber
, During an Insulin infusion for a client with diabetes mellitus who is
|! |! |! |! |! |! |! |! |! |! |! |!
experiencing hyperglycemic hyperosmolar syndrome in addition to the
|! |! |! |! |! |! |! |!
client's glucose, which laboratory value is most important for the nurse to
|! |! |! |! |! |! |! |! |! |! |! |!
monitor?
a. Urine ketones
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b. Urine albumin
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c. Serum protein
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d. Serum potassium - Correct answer ✔d. Serum potassium
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Rationale: Electrolyte shifts are common during correction of hyperosmolar
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and hyperglycemic states. Monitor electrolyte levels at least every 4
|! |! |! |! |! |! |! |! |! |! |!
hours, or every 2 hours if needed. Monitor serum sodium and potassium
|! |! |! |! |! |! |! |! |! |! |! |!
levels closely. If needed, use isotonic and hypotonic saline solutions to
|! |! |! |! |! |! |! |! |! |! |!
adjust the patient's sodium level. Despite major potassium loss during
|! |! |! |! |! |! |! |! |! |!
diuresis in early HHS stages, many patients initially present in a
|! |! |! |! |! |! |! |! |! |! |!
hyperkalemic state due to dehydration. When fluid and insulin therapy|! |! |! |! |! |! |! |! |! |!
begin, the serum potassium level may drop dramatically.
|! |! |! |! |! |! |!
In planning strategies to reduce a client's risk for complications following
|! |! |! |! |! |! |! |! |! |! |!
orthopedic surgery, the nurse recognizes which pathology as the
|! |! |! |! |! |! |! |! |!
underlying cause of osteomyelitis? |! |! |!
a. Infectious process
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b. Metastatic process
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c. Autoimmune disorder
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d. Inflammatory disorder - Correct answer ✔infectious process
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verified solutions |!
A client on a long-term mental health unit repeatedly takes own pulse
|! |! |! |! |! |! |! |! |! |! |! |!
regardless of the circumstance. What action should the nurse implement?
|! |! |! |! |! |! |! |! |!
a. Overlook the client's behavior.
|! |! |! |!
b. Distract client to interfere with the ritual.
|! |! |! |! |! |! |!
c. Ask why the client checks the pulse.
|! |! |! |! |! |! |!
d. Hold client's hand to stop the behavior. - Correct answer ✔Overlook the
|! |! |! |! |! |! |! |! |! |! |! |! |!
client's behavior. |!
A client is discharged with automated peritoneal dialysis (PD) to be used
|! |! |! |! |! |! |! |! |! |! |! |!
nightly...which instructions should the nurse include? |! |! |! |! |!
a. Wash hands before cleaning exit site
|! |! |! |! |! |!
b. Keep the head of the bed flat at night
|! |! |! |! |! |! |! |! |!
c. Feel for a thrill and a distal pulse nightly
|! |! |! |! |! |! |! |! |!
d. Do not get up if fluid is left in the abdomen - Correct answer ✔Wash
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
hands before cleaning exit site
|! |! |! |!
Rationale: meticulous hand hygiene is essential when performing care for
|! |! |! |! |! |! |! |! |! |!
a peritoneal dialysis, infections is a common complication of peritoneal
|! |! |! |! |! |! |! |! |! |!
dialysis.
,The charge nurse observes the practical nurse (PN) apply sterile gloves in
|! |! |! |! |! |! |! |! |! |! |! |!
preparation for performing a sterile dressing change. Which action by the
|! |! |! |! |! |! |! |! |! |! |!
PN requires correction by the charge nurse?
|! |! |! |! |! |!
a- Opening the package
|! |! |!
b- Picking up the second glove
|! |! |! |! |!
c- Picking up the first glove
|! |! |! |! |!
d- Positioning of the table - Correct answer ✔Picking up the second glove
|! |! |! |! |! |! |! |! |! |! |! |!
A young adult who is hit with a baseball bat on the temporal area of the
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
left skull is conscious when admitted to the ED and is transferred to the
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
Neurological Unit to be monitored for signs of closed head injury. Which |! |! |! |! |! |! |! |! |! |! |! |!
assessment finding is indicative of a developing epidural hematoma? |! |! |! |! |! |! |! |!
a. Altered consciousness within the first 24 hours after injury.
|! |! |! |! |! |! |! |! |!
b. Cushing reflex and cerebral edema after 24 hours
|! |! |! |! |! |! |! |!
c. Fever, nuchal rigidity and opisthotonos within hours
|! |! |! |! |! |! |!
d. Headache and pupillary changes 48 hours after a head injury - Correct
|! |! |! |! |! |! |! |! |! |! |! |! |!
answer ✔Altered consciousness within the first 24 hours after injury.
|! |! |! |! |! |! |! |! |!
A male client reports to the clinic nurse that he has been feeling well and
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
is often "dizzy" his blood pressure is elevated. Based on this findings, this
|! |! |! |! |! |! |! |! |! |! |! |! |!
client is at a greatest risk for which pathophysiological condition?
|! |! |! |! |! |! |! |! |!
a. Pulmonary hypertension
|! |!
b. Left ventricular hypertrophy
|! |! |!
,c. Renal failure
|! |!
d. Stroke - Correct answer ✔Stroke
|! |! |! |! |!
The nurse ask the parent to stay during the examination of a male
|! |! |! |! |! |! |! |! |! |! |! |! |!
toddler's genital area. Which intervention should the nurse implement?
|! |! |! |! |! |! |! |!
a. Examine the genitalia as the last part of the total exam.
|! |! |! |! |! |! |! |! |! |! |!
b. Use soothing statements to facilitate cooperation
|! |! |! |! |! |!
c. Allow the child to keep underpants on to examine genitalia
|! |! |! |! |! |! |! |! |! |!
d. Work slowly and methodically so not to stress the child - Correct answer
|! |! |! |! |! |! |! |! |! |! |! |! |!
✔Examine the genitalia as the last part of the total exam.
|! |! |! |! |! |! |! |! |! |! |!
Rationale: Examination of a child's genitalia is particularly stressful to
|! |! |! |! |! |! |! |! |! |!
toddles, so this assessment is best left as the last part of the examination.
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
B are best done by a parent, not the nurse. The genitals must be
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
completely visualized and sometimes palpates underwear for a brief period
|! |! |! |! |! |! |! |! |!
of.
|!
The nurse is changing a client's IV tubing and closes the roller clamp on
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
the new tubing setup when the bag of solution is _____. Which action
|! |! |! |! |! |! |! |! |! |! |! |! |!
should the nurse take to ensure adequate filling of the drip chamber?
|! |! |! |! |! |! |! |! |! |! |!
a. Lower the IV bag to a flat surface
|! |! |! |! |! |! |! |!
b. Compress the drip chamber
|! |! |! |!
c. Open the roller clamp
|! |! |! |!
d. Squeeze the bag of IV solution - Correct answer ✔Compress the drip
|! |! |! |! |! |! |! |! |! |! |! |! |!
chamber
, During an Insulin infusion for a client with diabetes mellitus who is
|! |! |! |! |! |! |! |! |! |! |! |!
experiencing hyperglycemic hyperosmolar syndrome in addition to the
|! |! |! |! |! |! |! |!
client's glucose, which laboratory value is most important for the nurse to
|! |! |! |! |! |! |! |! |! |! |! |!
monitor?
a. Urine ketones
|! |!
b. Urine albumin
|! |!
c. Serum protein
|! |!
d. Serum potassium - Correct answer ✔d. Serum potassium
|! |! |! |! |! |! |! |!
Rationale: Electrolyte shifts are common during correction of hyperosmolar
|! |! |! |! |! |! |! |!
and hyperglycemic states. Monitor electrolyte levels at least every 4
|! |! |! |! |! |! |! |! |! |! |!
hours, or every 2 hours if needed. Monitor serum sodium and potassium
|! |! |! |! |! |! |! |! |! |! |! |!
levels closely. If needed, use isotonic and hypotonic saline solutions to
|! |! |! |! |! |! |! |! |! |! |!
adjust the patient's sodium level. Despite major potassium loss during
|! |! |! |! |! |! |! |! |! |!
diuresis in early HHS stages, many patients initially present in a
|! |! |! |! |! |! |! |! |! |! |!
hyperkalemic state due to dehydration. When fluid and insulin therapy|! |! |! |! |! |! |! |! |! |!
begin, the serum potassium level may drop dramatically.
|! |! |! |! |! |! |!
In planning strategies to reduce a client's risk for complications following
|! |! |! |! |! |! |! |! |! |! |!
orthopedic surgery, the nurse recognizes which pathology as the
|! |! |! |! |! |! |! |! |!
underlying cause of osteomyelitis? |! |! |!
a. Infectious process
|! |!
b. Metastatic process
|! |!
c. Autoimmune disorder
|! |!
d. Inflammatory disorder - Correct answer ✔infectious process
|! |! |! |! |! |! |!
