HESI EXIT EXAM FINAL CAPSTONE 160 QUESTIONS (grade = 95.36)

1/ A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement? A. Instruct the mother to give the child sugar water only. B. Offer the infant oral rehydration solution every 2 hours. C. Provide Pedialyte feedings via the nasogastric tube. D. Maintain intravenous fluid therapy per prescription. Patient dehydration, electrolyte imbalance, metabolic alkalosis, aspiration, pneumonia NPO IV fluids 2/ A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results show that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important? A. Observe rhythm on telemetry monitor. (QL) B. Check for visual difficulties. C. Assess for hip and hand joint pain. D. Note most recent hemoglobin level. 3/ The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? A. An 8-year-old who lives in a housing project. B. A 2-year-old who plays on aging outdoor playground equipment. (QL) C. An adolescent who works part time in a paint factory. D. A 10-year-old who has Type 1 diabetes mellitus. 4/ The client provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eyeopener) questionnaire. Which interpretation should the nurse provide the client? A. The CAGE questionnaire is a tool used to identify general substance abuse. B. At least two positive responses are strongly suggestive of alcohol dependence. C. One positive response indicates the client should seek help with alcohol addiction. D. All responses to the CAGE questionnaire must be positive to suggest alcohol dependence. 5/ In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care? A. Evaluate closest proximal pulse. (QL) B. Note amount and color of wound drainage. C. Observe for swelling around the stump. D. Assess skin elasticity of the stump. 6/ An adolescent with intellectual disability is admitted to the adolescent unit for repeatedly refusing to complete oral hygiene. The healthcare provider prescribes for the client to brush the teeth three times a day. In the psychiatric team conference, a behavior modification program is recommended to engage the client’s participation. When implementing this technique, which reinforcement is best for the nurse to provide? A. Unit tasks for each omission of teeth brushing. B. Candy for each successful hygiene task, like brushing his teeth. C. Privilege restriction or fines for refusing to complete a hygienic task. D. Preferred activities or tokens for each compliance. (QL) 7/ A male client with HIV, who is receiving saquinavir PO in combination with other antiretroviral therapy, tells the home health nurse that he is always hungry and thirsty but seems to be losing weight. What action should the nurse implement? A. Use a glucometer to determine the client’s capillary glucose level. (QL) B. Teach the client strategies to ensure that he measures his weight accurately. C. Explain to the client that he may require an increased dose of his medication. D. Reassure the client that he will gain weight as his viral load decreases. 8/ A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the client’s therapeutic response to this medication, which assessment should the nurse obtain? A. Percussion of abdomen. B. Blood glucose level. C. Serum electrolytes. D. Level of consciousness. (QL) Cirrhosis = hepatic encephalopathy = cloudy brain from ammonia (protein waste) => cannot detox ammonia => build up in blood = mental status changes & twitching extremities 9/ A client with a history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain. Vital signs are: temperature 102F (38.9C), heart rate 138beats/minute, blood pressure 80/60 mmHg. Which intervention should the nurse implement first? A. Obtain an analgesic prescription. B. Infuse an intravenous fluid bolus. (QL) C. Administer PRN oral antipyretic. D. Cover client with cooling blanket. 10/ While changing a client’s chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take? A. Apply a pressure dressing around the chest tube insertion site. B. Administer an oral antihistamine per PRN protocol. x C. Assess the client for allergies to topical cleaning agents. D. Measure the area of swelling and crackling. (QL)