GENERATION VOLUMES ACTUAL EXAM ALL 800
QUESTIONS AND CORRECT DETAILED
ANSWERS|ALREADY GRADED A+\RN HESI TEST
BANK EXAM
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer. Her
Papanicolau (Pap) smear results are negative. What information should the nurse include
in the client's teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed.
Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer should be
evaluated carefully
,A client who recently underwent a tracheostomy is being prepared for discharge to
home. Which instructions is most important for the nurse to include in the discharge
plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site.
Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is
critical.
,In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which
client alarm should the nurse investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes.
Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea that should
be assessed first.
, During a home visit, the nurse observed an elderly client with diabetes slip and fall. What
action should the nurse take first?
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level
Check the client for lacerations or fractures
Rationale: After the client falls, the nurse should immediately assess for the possibility of
injuries and provide first aid as needed
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section),
the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to
avoid getting a headache. Which action should the nurse take first?
a. Ensure preoperative lab results are available
b. Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d. Contact the client's obstetrician.
Inform the anesthesia care provider
Rationale: Surgical preoperative instruction includes NPO after midnight the day of
surgery to decrease the risk of aspiration should vomiting occur during anesthesia. While
it is possible the C-section will be done on schedule or rescheduled for later in the day,
the anesthesia provider should be notified first.