HESI Exit RN EXIT EXAM V4
HESI Exit RN EXIT EXAM V4 Complete Verified
Questions and Correct Verified Answers/ RN
Hesi Exit Exam V4 for the RN Hesi Exit Prep
(New!)
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
A.
White blood cell count
B.
Albumin
C.
Calcium
D.
Sodium - Correct Answer :D
A+ TEST BANK 1
, HESI Exit RN EXIT EXAM V4
Rationale: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG
suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically
associated with prolonged NG suctioning.
The nurse is providing care to a client receiving sq heparin every 12 hours at 8:00 am and 8:00
pm. The healthcare provider prescribes an aPTT test. At what time will the nurse plan on drawing
the test?
A.
7:00 am
B.
9:00 am
C.
12:00 noon
D.
2:00 pm - Correct Answer :A
Rationale: The aPTT test should be drawn 1 hour before the scheduled dose.
The nurse is providing care to a client who had major abdominal surgery. Upon return from the
recovery room, the client's vital signs were at the pre-operative baseline. The client was sleepy,
but arousable, and the skin was warm and dry to the touch. At the 1 hour post admission
assessment the nurse notes: heart rate 120 and thready, B/P 70/40 mm Hg, and the skin is cool
and clammy to the touch. What are the priority nursing actions? (Select all that apply.)
A.
Call the health care provider.
B.
Elevate the head of the bed.
C.
Observe for restlessness/confusion.
D.
A+ TEST BANK 2
, HESI Exit RN EXIT EXAM V4
Administer oxygen by re-breather mask.
E.
Observe the abdominal bandage. - Correct Answer :A, C, D, E
Rationale: The client's is showing signs of hemorrhagic shock. This is a medical emergency. The
head of bed may need to be lowered or placed in Trendelenburg position to increase circulation
to the brain. The remaining selections are correct.
The nurse evaluates the insertion site of an IV catheter and suspects the IV is infiltrated. Which
findings support the evaluation? (Select all that apply.)
A.
The area around the insertion site is swollen.
B.
There is bruising 1 inch below the insertion site.
C.
The insertion site is cool to the touch.
D.
The client complains of a burning pain at the site.
E.
Redness is noted in the area of the insertion site.
F.
Blood is noted in the IV tubing when the IV bag is lowered. - Correct Answer :A, C, D, E
Rationale: Bruising is an accumulation of blood under the skin, most likely from oozing with the
insertion of the IV. When blood is noted in the IV tubing when the IV bag is lowered, that is a sign
of patency. The remaining signs are related to infiltration.
At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR was hung at 1845.
The prescribed infusion rate is 75 mL/hr. The oncoming nurse assesses the client at 1915 and
notes there is less than 50 mL left in the IV bag. What is the nurse's next action?
A.
A+ TEST BANK 3
, HESI Exit RN EXIT EXAM V4
Contact the healthcare provider on call.
B.
Call in the off going nurse and request an explanation.
C.
Tell the client that 950 mL of fluid just accidentally infused.
D.
Auscultate the client's lungs. - Correct Answer :D
Rationale: The client may show signs of fluid overload, such as crackles. Other respiratory signs
are dyspnea and increased rate. Assess the client's reaction to the fluid bolus first and then
proceed with notifying the charge nurse and the health care provider.
The health care provider has changed a client's prescription from the PO to the IV route of
administration. The nurse should anticipate which change in the pharmacokinetic properties of
the medication?
A.
The client will experience increased tolerance to the drug's effects and may need a higher dose.
B.
The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
C.
The medication will be more highly protein-bound, increasing the duration of action.
D.
The therapeutic index will be increased, placing the client at greater risk for toxicity. - Correct
Answer :B
Rationale: Because the absorptive process is eliminated when medications are administered via
the IV route, the onset of action is more rapid, resulting in a more immediate effect. Drug
tolerance, protein binding, and the drug's therapeutic index are not affected by the change in
route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.
A+ TEST BANK 4
HESI Exit RN EXIT EXAM V4 Complete Verified
Questions and Correct Verified Answers/ RN
Hesi Exit Exam V4 for the RN Hesi Exit Prep
(New!)
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
A.
White blood cell count
B.
Albumin
C.
Calcium
D.
Sodium - Correct Answer :D
A+ TEST BANK 1
, HESI Exit RN EXIT EXAM V4
Rationale: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG
suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically
associated with prolonged NG suctioning.
The nurse is providing care to a client receiving sq heparin every 12 hours at 8:00 am and 8:00
pm. The healthcare provider prescribes an aPTT test. At what time will the nurse plan on drawing
the test?
A.
7:00 am
B.
9:00 am
C.
12:00 noon
D.
2:00 pm - Correct Answer :A
Rationale: The aPTT test should be drawn 1 hour before the scheduled dose.
The nurse is providing care to a client who had major abdominal surgery. Upon return from the
recovery room, the client's vital signs were at the pre-operative baseline. The client was sleepy,
but arousable, and the skin was warm and dry to the touch. At the 1 hour post admission
assessment the nurse notes: heart rate 120 and thready, B/P 70/40 mm Hg, and the skin is cool
and clammy to the touch. What are the priority nursing actions? (Select all that apply.)
A.
Call the health care provider.
B.
Elevate the head of the bed.
C.
Observe for restlessness/confusion.
D.
A+ TEST BANK 2
, HESI Exit RN EXIT EXAM V4
Administer oxygen by re-breather mask.
E.
Observe the abdominal bandage. - Correct Answer :A, C, D, E
Rationale: The client's is showing signs of hemorrhagic shock. This is a medical emergency. The
head of bed may need to be lowered or placed in Trendelenburg position to increase circulation
to the brain. The remaining selections are correct.
The nurse evaluates the insertion site of an IV catheter and suspects the IV is infiltrated. Which
findings support the evaluation? (Select all that apply.)
A.
The area around the insertion site is swollen.
B.
There is bruising 1 inch below the insertion site.
C.
The insertion site is cool to the touch.
D.
The client complains of a burning pain at the site.
E.
Redness is noted in the area of the insertion site.
F.
Blood is noted in the IV tubing when the IV bag is lowered. - Correct Answer :A, C, D, E
Rationale: Bruising is an accumulation of blood under the skin, most likely from oozing with the
insertion of the IV. When blood is noted in the IV tubing when the IV bag is lowered, that is a sign
of patency. The remaining signs are related to infiltration.
At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR was hung at 1845.
The prescribed infusion rate is 75 mL/hr. The oncoming nurse assesses the client at 1915 and
notes there is less than 50 mL left in the IV bag. What is the nurse's next action?
A.
A+ TEST BANK 3
, HESI Exit RN EXIT EXAM V4
Contact the healthcare provider on call.
B.
Call in the off going nurse and request an explanation.
C.
Tell the client that 950 mL of fluid just accidentally infused.
D.
Auscultate the client's lungs. - Correct Answer :D
Rationale: The client may show signs of fluid overload, such as crackles. Other respiratory signs
are dyspnea and increased rate. Assess the client's reaction to the fluid bolus first and then
proceed with notifying the charge nurse and the health care provider.
The health care provider has changed a client's prescription from the PO to the IV route of
administration. The nurse should anticipate which change in the pharmacokinetic properties of
the medication?
A.
The client will experience increased tolerance to the drug's effects and may need a higher dose.
B.
The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
C.
The medication will be more highly protein-bound, increasing the duration of action.
D.
The therapeutic index will be increased, placing the client at greater risk for toxicity. - Correct
Answer :B
Rationale: Because the absorptive process is eliminated when medications are administered via
the IV route, the onset of action is more rapid, resulting in a more immediate effect. Drug
tolerance, protein binding, and the drug's therapeutic index are not affected by the change in
route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.
A+ TEST BANK 4
