HESI EXIT RN 2022 V3 160 Questions

HESI EXIT RN 2022 V3 160 Questions 1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? a. Measure and document the client’s urinary output. b. Request the client’s reservedunit if packed red blood cells. c. Prepare the placement of a central venous catheter. d. Increase the infusion rate of Lactated Ringer’s solution. 2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensivecare unit (ICU). the nurse notesthat the suction control chamber is bubbling at the - 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention shouldthe nurse implement? a. Add sterile water to the suction control chamber. b. Give blood from the collection chamber as autotransfusion c. Manipulate blood in tubing to drain into chamber. d. Increase wall suction to eliminatefluctuation in water seal. 3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? a. Elevate the foot of the bed. b. Restrict the client’s fluid. c. Begin supplemental oxygen. d. Prepare the client forhemodialysis. 4. A client with Addison’s crisis is admitted for treatment with adrenalcortical supplementation. Based on the client’s admitting diagnosis, which findings require immediateaction by the nurse? (Select all that apply) a. Headache and tremors b. Irregular heart rate c. Skin hyperpigmentation d. Postural hypotension e. Pallorand diaphoresis 5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? a. Urine specificgravity is 1.040 b. Systolicblood pressure decreases 10 points when standing. c. The client denies being thirsty. d. Skin tenting occurs when the client’sforearm is pinched. 6. After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? a. File adetailed incident report withthe specifichiring facility. b. Warn the colleague that theiractionsare unprofessional. c. Comment anonymously about the action of astaff discussion board. d. Communicate the colleague’s actionsto the unit charge nurse. 7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in arural health clinic. Which outcomeindicatethe program is effective? a. At-risk clientsreceivedan increased number of routine health screenings. b. Clients reported havingnew confidence in making healthy food choices. c. Clients who incurred diseasecomplications promptly received rehabilitation. d. Client relapserate of 30% in a 5-yearcommunity-wideanti-smoking campaign. 8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? a. Determine if the clientis experiencing any anxiety. b. Auscultate the client’sbilateral lung sounds and oxygen saturation. c. Notify the healthcareprovider about the client’s distress. d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula. 9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediateinvestigation by the nurse? a. “When I get out of bed quickly, I feel a littledizzy.” b. “The dressing overmy incision feelslikeit is too tight.” c. “I’m most comfortable when the head of the bed is raised.” d. “This IV infusion makes me urinate more often than usual.” 10. An older adult male who is in his early 70’s is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client’s living will. Which acti on should the nurse take? a. Facilitate a family meeting with the palliative care team. b. Notify the healthcare provider of the client’s wishes. c. Place a certifiedcopy of the living willin the client’s record. d. Alert the nursing staff of the client’s don’t resuscitate status. 11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurserespond? a. Determine the client’s levelof mobility and need forassistance. b. Instruct the UAP that all clients deserveequalcare. c. Advice the client to maintainbedrest so that safety can be ensured. d. Assign another UAP to care forthe client. 12. A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at the parent-teacher meeting. What action is most important forthe nurse to include in the meeting? a. Provide informationon ways to increase activity forthe family. b. Have several teachers talk about health risks associated with obesity. c. Distribute a shopping list of suggestedhealthy snack items. d. Determine the parents’ degreeof concern about theirchildren’s weight. 13. After several months of chronic fatigue, morning stiffness, and join pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse providethe client with regard to taking prednisone? a. Take prednisone doses before meals on an empty stomach. b. Wearsunglasses whenexposed to bright sunlight. c. If sequentialdoses are missed, notify thehealthcare provider. d. Schedule amonthly laboratory visit foracomplete blood count. 14. The psychiatricnurse is caring forclients on an adolescent unit. Which client requires the nurse’s immediate attention? a. A 16-year-old client diagnosed with majordepression whorefuses to participatein group. b. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. c. An 18-year-old client withantisocial behavior who is being yelled at by other clients d. A 17-year-old client diagnosed withbipolar disorder who is pacing around the lobby.. 15. The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms? a. Positive Epstein-Barr, and malaise. b. Ear pain and fever. c. Elevated WBC and sedimentation rate. d. Increased BUN and serum creatinine. 16. A client arrives for an annual physical exam and complains of having calf pain. The client’s health history reveals peripheral atrial disease. Which question should the nurse ask the client about expected finding related to chronicarterial symptoms? a. Were yourlegs eversuddenly swollen, red, warm, and painful? b. Does the calf pain occur when walking short distances? c. Did you receive treatment for weeping ulcerson lower legs? d. Have you experiencedankle edema and varicoseveins? 17. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure? a. Drank a glass of water in the past 2 hours. b. Reports left chest wall pain prior to admission. c. Verbalize a fear of being in a confined space. d. Experience facialswellingaftereating crab. 18. The nurse is assessing a 4-year-old child with eczema. The child’s skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated forcare of this child? a. Keep the nails trimmed short. b. Apply baby lotion to the skin twice daily. c. Bathe the child daily with bath oil. d. Allow the child to wearonly 100% cotton clothing. 19. A new mother on the postpartum unit runs out of the room screaming that her newborn infant’s crib is empty and the baby is missing. What action should the nurse take first? a. Determine if the newborn is in the nursery. b. Activate the lockdownprocedure. c. Ask the mother if any visitors were expected to arrive. d. Match ID bands of all infants and mothers on the unit. 20. While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important forthe nurse to ask? a. “Do you often have feeling of sadness?” b. “Are you having problems concentrating?” c. “Have you though about taking your life?” d. “What problems are you facing right now?” 21. A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, “kill, kill.” What question should the nurse ask the client next? a. “When did these voices begin?” b. “Have you taken any hallucinogens?” c. “Are you planning to obey the voices?” d. “Do you believe the voices are real?” 22. The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? a. The client will express acceptance of theirnewly diagnosedhealth status. b. The nurse will encourage the client to walk thirty minutes everyday. c. The client’s blood pressure readings will be less than 160/90 mmHg. d. The client’s skin on the lower legswillbe intact at the next clinical visit. 23. When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (select all that apply.) a. . Fruits without sauce b. Canned soup. c. Fresh or frozen vegetables without sauce. d. Cottage cheese. e. Pickled olives. 24. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indicationto the nurse that the client is experiencing atherapeuticresponse to the phenytoin? a. Increased time of ambulation between periods of rest. b. Decrease in intracranial pressure and cerebral edema. c. Absence of seizure activity forthe duration of treatment. d. Normal electroencephalogram afterdrug administration. 25. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all that apply) c. Widens stance whileworking nearthe sink. d. Bends from the waist to pick trash off the floor. e. Leans forward to pull a pan from a high shelf. 26. An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What interventionshouldthe nurse implement first? a. Document neurologicchanges. b. Reduce environmental stimuli. c. Administer prescribed neuroleptic. d. Review medications for interactions.