Hesi Exit Rn V2 Exam New all Pages allrs||Latest updated 2025

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The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client
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has a current blood glucose level of 720 mg/dL. When assessing the client, what is the priority?
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A. Assess for signs of fluid volume deficit n n n n n n




B. Observe wound drainage characteristics n n n




C. Measure the level of acute pain n n n n n




D. Determine when the client last ate - ✅✅A. Assess for signs offluid volume deficit n n n n n n n n n n n n n n




A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he isexperiencing
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heartburn and dull gnawing pain that is relieved when he eats. Which is the best response by the
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A. Encourage the client to obtaina complete physicalexam, since these symptoms are consistent with an ul
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cer
b




B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food
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C. Instruct the client that these mild symptoms cangenerally be controlled withchanges in his diet
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D. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms -
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H b ✅✅A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with
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an ulcer n




A male client withstomachcancer returns to the unit following a total gastrectomy. He has a nasogastric tube
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to suction and is receiving Lactated Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the
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nurse notes 300mL of blood in the suction canister, the client's heart rate is 155 beats/minute,
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pressure is 78/48 mmHg. In addition to reporting the findings to the surgeon, which action should the nurse i
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mplement first?
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A. Measure and document the client's urinary output n n n n n n




B. Request the client's reserved unit of packed red blood cells n n n n n n n n n




C. Prepare for placement of a centralvenous catheter n n n n n n n




D. Increase the infusion rate ofLactated Ringer's solution - n n n n n n n n




✅✅D. Increase the infusion rate of Lactated Ringer's solution
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,P a ge 1 | 44
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,and
A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80
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uni ts/kg, the nurse calculates the infusion rate for the heparin solution as 18 units/kg/hour. The
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bavailable soluti on is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should
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bprogram the infusion pump to deliver how many mL/hour? -✅✅-1st: calculate the weight = 220/2.2=
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100kg
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-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
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- 25000 units -
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bn in 250 1800 units ---
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b in X ml n n




x = 1800 x 250/25000 =18 mL/hr
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An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax.
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bChest tubes were inserted in the emergency departmentprior to his transfer to the
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intensive care unit (ICU). Th e nurse notes that the suction control chamber is bubbling at the -
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10cm H2O n H bH




mark, which fluctuation in the water seal, and over the past hour 75 mL of bright red blood is meas ured in
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bthe collection chamber. Which intervention should the nurse implement?
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A. Add sterile water to the suction control chamber
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B. Give blood from the collection chamber as autotransfusion
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C. Manipulate blood intubing to drain into chamber n n n n n n n




D. Increase wall suction to eliminate fluctuation in water seal - n n n n n n n n n




b✅✅A. Add sterile water to the suction
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bcontrol chamber
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An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and
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basks how she will know that her husband's death is imminent because their two adult children want to be
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ther e when he dies. Which is the best response by the nurse?
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A. Gather information regarding how long it will take for the childrento arrive
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B. Explain that the client will start to lose consciousness and the body systems will slow down
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C. Reassure the spouse that the healthcare provider will notify when to call the children
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D. Offer to discuss the client's health status with each of the adult children -
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b✅✅B. Explain that the
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bclient will start to lose consciousness and the body systems will slow down
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The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal
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numb
b n er of registered nurses will be working that shift. In planning assignments, which client should
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breceive the mo st care hours by a registered nurse (RN)?
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, Pa ge
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