INET HESI RN V4 ACTUAL TEST
SCREENSHOTS PROCTORED EXAM
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to
prevent complications of immobility. Which action should be included in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. A
Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around
joints. Options B, C, and D are all potentially harmful practices that place the immobile client at
risk of complications.
The nurse administered 10 mg of diazepam to the preoperative client. What steps will the nurse
take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
,Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom B, C, D
Rationale: Diazepam is a common preoperative medication. Close observation by placing the
client close to the nurse's station is not necessary. The medication has a sedative effect and the
client should not get out of bed, even with assistance. The remaining selections are correct.
A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die."
Which is the best response for the nurse to provide?
A.
Administer the prescribed maximum dose of pain medication.
B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant therapy.
D.
Refer the client to the ethics committee of her local health care facility. B
Rationale: The nurse should first assess the client's feelings about death and determine the extent
to which this statement expresses the client's true feelings. The client may need additional pain
management, but further assessment is needed before implementing option A. Options C and D
are both premature interventions and should not be implemented until further assessment is
obtained.
"Do you usually bathe/shower in the morning or in the evening?"
C.
"Do you have any intolerance to food that we need to know about?"
D.
"How long do you think you will be here on the rehabilitation unit?"
E.
"Do you urinate every hour, on the hour, when you are awake?" A, B, C, D
Rationale: The goal of the intake interview is to understand the client's daily routines so those
routines can be observed and upheld while residing on the rehabilitation unit. Asking about how
long the client will be on the rehabilitation unit helps the nurse to understand the client's
expectations of the duration of the stay. Urinary and bowel patterns are important to understand,
but the issue with this assessment is the frequency of urination. The better question is, "How
often do you urinate when you are awake?"
The nurse identifies a potential for infection in a client with partial-thickness (second-degree)
and full-thickness (third-degree) burns. What action has the highest priority in decreasing the
client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
, D.
Limiting visitors to the client with burns B
Rationale: Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. Option A reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective organisms.
Options C and D are recommended by various burn centers as possible ways to reduce the
chance of infection. Option B is a proven technique to prevent infection.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV
rate by gravity has slowed, even though the venous access site is healthy. What should the nurse
do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate. B
Rationale: The nurse should first check the tubing and height of the bag on the IV pole, which
are common factors that may slow the rate. Gravity infusion rates are influenced by the height of
the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood
pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often
responds to warmth over the vessel, but the nurse should first adjust the IV pole height. The
nurse may need to adjust the stabilizing tape on a positional needle or flush the venous access
with normal saline, but less invasive actions should be implemented first.
The nurse is providing care to a client immediately after a total right mastectomy. What steps
will the nurse include when positioning the client? (Select all that apply.)
A.
Raise the head of the bed 30 to 45 degrees.
B.
Roll the client to her right side and place a pillow behind her back.
C.
Elevate her right arm under two pillows.
D.
Require the client to stay in bed for 72 hours post procedure.
E.
Place a sandbag on the incision. A, C
Rationale: The client must stay on her back or on the unaffected side, not on the operative side.
Mobility as tolerated; there is no need to remain immobile. A sandbag is used when there is risk
of bleeding from the wound. There is no mention of that risk in the stem. Sitting up and elevating
the arm will help lymph drainage.
, The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the
risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse
to provide to this client?
A.
"Monitoring Your Blood Pressure at Home"
B.
"Smoking Cessation as a Lifelong Commitment"
C.
"Decreasing Cholesterol Levels Through Diet"
D.
"Stress Management for a Healthier You" C
Rationale: A health promotion brochure about decreasing cholesterol is most important to
provide this client, because the most significant risk factor contributing to development of
arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Option A does not
address the underlying causes of arteriosclerosis. Options B and D are also important factors for
reversing arteriosclerosis but are not as important as lowering cholesterol.
The nurse is preparing the room for a client after a laparotomy with a 5 inch midline abdominal
incision. The nurse plans on teaching the client how to splint the wound when coughing or deep
breathing. What extra item will the nurse place in the client's room?
A.
Pillow case
B.
Pillow
C.
Sheet
D.
Blue absorbent pad B
Rationale: The purpose of splinting an incision is to offer additional support to the wound. The
client can hold a pillow or rolled up blanket against the abdominal incision. The remaining items
do not offer the level of support necessary to splint the wound.
A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive
and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the
leg amputated and sues the nurse for malpractice. Which statement reflects the likely outcome
for the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the
case.
B.
The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
C.
There will be no judgment against the nurse, whose actions are protected under the Good
Samaritan Act.
D.
SCREENSHOTS PROCTORED EXAM
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to
prevent complications of immobility. Which action should be included in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. A
Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around
joints. Options B, C, and D are all potentially harmful practices that place the immobile client at
risk of complications.
The nurse administered 10 mg of diazepam to the preoperative client. What steps will the nurse
take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
,Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom B, C, D
Rationale: Diazepam is a common preoperative medication. Close observation by placing the
client close to the nurse's station is not necessary. The medication has a sedative effect and the
client should not get out of bed, even with assistance. The remaining selections are correct.
A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die."
Which is the best response for the nurse to provide?
A.
Administer the prescribed maximum dose of pain medication.
B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant therapy.
D.
Refer the client to the ethics committee of her local health care facility. B
Rationale: The nurse should first assess the client's feelings about death and determine the extent
to which this statement expresses the client's true feelings. The client may need additional pain
management, but further assessment is needed before implementing option A. Options C and D
are both premature interventions and should not be implemented until further assessment is
obtained.
"Do you usually bathe/shower in the morning or in the evening?"
C.
"Do you have any intolerance to food that we need to know about?"
D.
"How long do you think you will be here on the rehabilitation unit?"
E.
"Do you urinate every hour, on the hour, when you are awake?" A, B, C, D
Rationale: The goal of the intake interview is to understand the client's daily routines so those
routines can be observed and upheld while residing on the rehabilitation unit. Asking about how
long the client will be on the rehabilitation unit helps the nurse to understand the client's
expectations of the duration of the stay. Urinary and bowel patterns are important to understand,
but the issue with this assessment is the frequency of urination. The better question is, "How
often do you urinate when you are awake?"
The nurse identifies a potential for infection in a client with partial-thickness (second-degree)
and full-thickness (third-degree) burns. What action has the highest priority in decreasing the
client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
, D.
Limiting visitors to the client with burns B
Rationale: Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. Option A reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective organisms.
Options C and D are recommended by various burn centers as possible ways to reduce the
chance of infection. Option B is a proven technique to prevent infection.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV
rate by gravity has slowed, even though the venous access site is healthy. What should the nurse
do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate. B
Rationale: The nurse should first check the tubing and height of the bag on the IV pole, which
are common factors that may slow the rate. Gravity infusion rates are influenced by the height of
the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood
pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often
responds to warmth over the vessel, but the nurse should first adjust the IV pole height. The
nurse may need to adjust the stabilizing tape on a positional needle or flush the venous access
with normal saline, but less invasive actions should be implemented first.
The nurse is providing care to a client immediately after a total right mastectomy. What steps
will the nurse include when positioning the client? (Select all that apply.)
A.
Raise the head of the bed 30 to 45 degrees.
B.
Roll the client to her right side and place a pillow behind her back.
C.
Elevate her right arm under two pillows.
D.
Require the client to stay in bed for 72 hours post procedure.
E.
Place a sandbag on the incision. A, C
Rationale: The client must stay on her back or on the unaffected side, not on the operative side.
Mobility as tolerated; there is no need to remain immobile. A sandbag is used when there is risk
of bleeding from the wound. There is no mention of that risk in the stem. Sitting up and elevating
the arm will help lymph drainage.
, The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the
risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse
to provide to this client?
A.
"Monitoring Your Blood Pressure at Home"
B.
"Smoking Cessation as a Lifelong Commitment"
C.
"Decreasing Cholesterol Levels Through Diet"
D.
"Stress Management for a Healthier You" C
Rationale: A health promotion brochure about decreasing cholesterol is most important to
provide this client, because the most significant risk factor contributing to development of
arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Option A does not
address the underlying causes of arteriosclerosis. Options B and D are also important factors for
reversing arteriosclerosis but are not as important as lowering cholesterol.
The nurse is preparing the room for a client after a laparotomy with a 5 inch midline abdominal
incision. The nurse plans on teaching the client how to splint the wound when coughing or deep
breathing. What extra item will the nurse place in the client's room?
A.
Pillow case
B.
Pillow
C.
Sheet
D.
Blue absorbent pad B
Rationale: The purpose of splinting an incision is to offer additional support to the wound. The
client can hold a pillow or rolled up blanket against the abdominal incision. The remaining items
do not offer the level of support necessary to splint the wound.
A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive
and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the
leg amputated and sues the nurse for malpractice. Which statement reflects the likely outcome
for the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the
case.
B.
The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
C.
There will be no judgment against the nurse, whose actions are protected under the Good
Samaritan Act.
D.
