HESI 799 RN EXIT UPDATED STUDY GUIDE QUESTIONS
AND ANSWERS MARKED A+
✔✔The fire alarm goes off while the charge nurse is receiving the shift report. What
action should the charge nurse implement first?
a. Instruct the client's family member to stay in the visitor waiting area until further notice
b. Tell the staff to keep all clients and visitors in the client rooms with the doors closed.
c. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly
manner.
d. Call the hospital operator to determine if the is indeed a real emergency or a fire drill.
- ✔✔Tell the staff to keep all clients and visitors in the client rooms with the doors
closed
Rationale: The charge nurse should treat the alarm as an actual fire emergency and
instruct all clients and visitors to stay in the clients' room with doors closed until
otherwise notified. A should be anxiety producing. Visitors should remain in the rooms
with the clients. C is only necessary if the location and severity of the fire make the unit
unsafe for inhabitants and would only be implemented after other measures to control
de fire had failed. D should not be done until after measures are taken to protect clients
and visitors.
✔✔A 60-year-old female client asks the nurse about hormones replacement therapy
(HRT) as a means preventing osteoporosis. Which factor in the client's history is a
possible contraindication for the use of HRT?
a. Her mother and sister have a history of breast cancer - ✔✔Her mother and sister
have a history of breast cancer
✔✔A male client, who is 24 hours postoperative for an exploratory laparotomy,
complains that he is "starving" because he has had no "real food" since before the
surgery. Prior to advancing his diet, which intervention should the nurse implement?
a. Discontinue intravenous therapy
b. Obtain a prescription for a diet change
c. Assess for abdominal distention and tenderness.
d. Auscultate bowel sounds in all four quadrants - ✔✔Auscultate bowel sounds in all
four quadrants
✔✔The nurse working in the psychiatric clinic has phone messages from several
clients. Which call should the nurse return first?
a. A young man with schizophrenia who wants to stop taking his medication
b. The mother of a child who was involved in a physical fight at school today.
c. A client diagnosed with depression who is experiencing sexual dysfunction.
, d. A family member of a client with dementia who has been missing for five hours -
✔✔A family member of a client with dementia who has been missing for five hours
Rationale: safety is always the priority concern and the family member of the missing
client with dementia needs assistance with contacting authorities as well as
psychological support during this time.
✔✔During change of shift, the nurse reports that a male client who had abdominal
surgery yesterday increasingly confused and disoriented during the night. He wandered
into other clients rooms, saying that there are men in his room trying to hurt him.
Because of continuing disorientation and the client's multiple attempts to get of bed, soft
restrains were applied at 0400. In what order should the nurse who is receiving report
implement these interventions? (Arrange from first action on top to last on the bottom)
1. Assess the client's skin and circulation for impairment related to the restrains
2. Evaluate the client's mentation to determine need to continue the restrains
3. Assign unlicensed assistive personnel to remove restrains and remain with client
4. Contact the client's surgeon and primary healthcare provider - ✔✔1. Assess the
client's skin and circulation for impairment related to the restrains
2. Evaluate the client's mentation to determine need to continue the restrains
3. Assign unlicensed assistive personnel to remove restrains and remain with client
4. Contact the client's surgeon and primary healthcare provide
✔✔A mother brings her 3-year-old son to the emergency room and tells the nurse the
he has had an upper respiratory infection for the past two days. Assessment of the child
reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more
restless. What action should the nurse take first?
a. Put a cold cloth on his head and administer acetaminophen.
b. Listen to lung sounds and place him in a mist tent.
c. Notify the healthcare provider and obtain a tracheostomy tray
d. Assist the child to lie down and examine his throat. - ✔✔Notify the healthcare
provider and obtain a tracheostomy tray
Rationale: This child exhibiting signs and symptoms of epiglottitis, a bacterial infection
causing acute airway obstruction, so is the immediate action to take.
✔✔After receiving the first dose of penicillin, the client begins wheezing and has trouble
breathing. The nurse notifies the healthcare provider immediately and received several
prescriptions. Which medication prescription should the nurse administer first?
a. Epinephrine Injection, USP IV
b. Diphenhydramine IV
c. Albuterol (Ventolin) inhaler
d. Methylprednisolone IV - ✔✔Epinephrine Injection, USP IV
AND ANSWERS MARKED A+
✔✔The fire alarm goes off while the charge nurse is receiving the shift report. What
action should the charge nurse implement first?
a. Instruct the client's family member to stay in the visitor waiting area until further notice
b. Tell the staff to keep all clients and visitors in the client rooms with the doors closed.
c. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly
manner.
d. Call the hospital operator to determine if the is indeed a real emergency or a fire drill.
- ✔✔Tell the staff to keep all clients and visitors in the client rooms with the doors
closed
Rationale: The charge nurse should treat the alarm as an actual fire emergency and
instruct all clients and visitors to stay in the clients' room with doors closed until
otherwise notified. A should be anxiety producing. Visitors should remain in the rooms
with the clients. C is only necessary if the location and severity of the fire make the unit
unsafe for inhabitants and would only be implemented after other measures to control
de fire had failed. D should not be done until after measures are taken to protect clients
and visitors.
✔✔A 60-year-old female client asks the nurse about hormones replacement therapy
(HRT) as a means preventing osteoporosis. Which factor in the client's history is a
possible contraindication for the use of HRT?
a. Her mother and sister have a history of breast cancer - ✔✔Her mother and sister
have a history of breast cancer
✔✔A male client, who is 24 hours postoperative for an exploratory laparotomy,
complains that he is "starving" because he has had no "real food" since before the
surgery. Prior to advancing his diet, which intervention should the nurse implement?
a. Discontinue intravenous therapy
b. Obtain a prescription for a diet change
c. Assess for abdominal distention and tenderness.
d. Auscultate bowel sounds in all four quadrants - ✔✔Auscultate bowel sounds in all
four quadrants
✔✔The nurse working in the psychiatric clinic has phone messages from several
clients. Which call should the nurse return first?
a. A young man with schizophrenia who wants to stop taking his medication
b. The mother of a child who was involved in a physical fight at school today.
c. A client diagnosed with depression who is experiencing sexual dysfunction.
, d. A family member of a client with dementia who has been missing for five hours -
✔✔A family member of a client with dementia who has been missing for five hours
Rationale: safety is always the priority concern and the family member of the missing
client with dementia needs assistance with contacting authorities as well as
psychological support during this time.
✔✔During change of shift, the nurse reports that a male client who had abdominal
surgery yesterday increasingly confused and disoriented during the night. He wandered
into other clients rooms, saying that there are men in his room trying to hurt him.
Because of continuing disorientation and the client's multiple attempts to get of bed, soft
restrains were applied at 0400. In what order should the nurse who is receiving report
implement these interventions? (Arrange from first action on top to last on the bottom)
1. Assess the client's skin and circulation for impairment related to the restrains
2. Evaluate the client's mentation to determine need to continue the restrains
3. Assign unlicensed assistive personnel to remove restrains and remain with client
4. Contact the client's surgeon and primary healthcare provider - ✔✔1. Assess the
client's skin and circulation for impairment related to the restrains
2. Evaluate the client's mentation to determine need to continue the restrains
3. Assign unlicensed assistive personnel to remove restrains and remain with client
4. Contact the client's surgeon and primary healthcare provide
✔✔A mother brings her 3-year-old son to the emergency room and tells the nurse the
he has had an upper respiratory infection for the past two days. Assessment of the child
reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more
restless. What action should the nurse take first?
a. Put a cold cloth on his head and administer acetaminophen.
b. Listen to lung sounds and place him in a mist tent.
c. Notify the healthcare provider and obtain a tracheostomy tray
d. Assist the child to lie down and examine his throat. - ✔✔Notify the healthcare
provider and obtain a tracheostomy tray
Rationale: This child exhibiting signs and symptoms of epiglottitis, a bacterial infection
causing acute airway obstruction, so is the immediate action to take.
✔✔After receiving the first dose of penicillin, the client begins wheezing and has trouble
breathing. The nurse notifies the healthcare provider immediately and received several
prescriptions. Which medication prescription should the nurse administer first?
a. Epinephrine Injection, USP IV
b. Diphenhydramine IV
c. Albuterol (Ventolin) inhaler
d. Methylprednisolone IV - ✔✔Epinephrine Injection, USP IV
