HESI 799 RN EXIT UPDATED QUESTIONS AND ANSWERS
MARKED A+
✔✔Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media.
An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What
instruction should the nurse emphasize concerning the installation of the antipyrine/
benzocaine otic solution?
a. Place the dropper on the upper outer ear canal and instill the medication slowly.
b. Warm the medication in the microwave for 10 seconds before instilling.
c. Keep the medication refrigerated between administrations.
d. Have the child lie with the ear up for one to two minutes after installation. - ✔✔d.
Have the child lie with the ear up for one to two minutes after installation.
✔✔An older adult male is admitted with complications related to chronic obstructive
pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion
and his weakness has increased over the past month. The nurse notes that he has
dependent edema in both lower legs. Based on these assessment findings, which
dietary instruction should the nurse provide?
a. Limit the intake of high calorie foods.
b. Eat meals at the same time daily.
c. Maintain a low protein diet.
d. Restrict daily fluid intake. - ✔✔Restrict daily fluid intake.
Rationale: the client is exhibiting signs of Cor pulmonale, a complication of COPD that
causes the right side of the heart to fail. Restricting fluid intake to 1000 to 2000 ml/day,
eating a high-calorie diet at small frequent meals with foods that are high in protein and
low in sodium can help relieve the edema and decrease workload on the right-side of
the heart.
✔✔The nurse inserts an indwelling urinary catheter as seen in the video what action
should the nurse take next?
a. Remove the catheter and insert into urethral opening
b. Observe for urine flow and then inflate the balloon.
c. Insert the catheter further and observe for discomfort.
d. Leave the catheter in place and obtain a sterile catheter. - ✔✔Leave the catheter in
place and obtain a sterile catheter.
✔✔A client with coronary artery disease who is experiencing syncopal episodes is
admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy.
Which intervention should the nurse delegate to the unlicensed assistive personnel
(UAP)?
, a. Prepare the skin for procedure.
b. Identify client's pulse points
c. Witness consent for procedure
d. Check telemetry monitoring - ✔✔Prepare the skin for procedure.
✔✔Following an outbreak of measles involving 5 students in an elementary school,
which action is most important for the school nurse to take?
a. Review the immunization records of all children in the elementary school
b. Report the measles outbreak to all community health organizations
c. Schedule a mobile public health vehicle to offer measles inoculations to unvaccinated
children.
d. Restrict unvaccinated children from attending school until measles outbreak is
resolved. - ✔✔Restrict unvaccinated children from attending school until measles
outbreak is resolved.
✔✔A preeclamptic client who delivered 24h ago remains in the labor and delivery
recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her
total input is limited to 125 ml per hour, and her urinary output for the last hour was 850
ml. What intervention should the nurse implement?
a. discontinue the magnesium sulfate immediately
b. Decrease the client's iv rate to 50 ml per hour
c. Continue with the plan of care for this client
d. Change the client's to NPO status - ✔✔c. Continue with the plan of care for this client
Rationale: continue with the plan. Diuresis in 24 to 48h after birth is a sign of
improvement in the preeclamptic client. As relaxation of arteriolar spasms occurs,
kidney perfusion increases. With improvement perfusion, fluid is drawn into the
intravascular bed from the interstitial tissue and then cleared by the kidneys
✔✔The nurse is planning care for a client who admits having suicidal thoughts. Which
client behavior indicates the highest risk for the client acting on these suicidal thoughts?
a. Express feelings of sadness and loneliness
b. Neglects personal hygiene and has no appetite
c. Lacks interest in the activity of the family and friends
d. Begin to show signs of improvement in affect - ✔✔Begin to show signs of
improvement in affect
✔✔When assessing a multigravida the first postpartum day, the nurse finds a moderate
amount of lochia rubra, with the uterus firm, and three fingerbreadths above the
umbilicus. What action should the nurse implement first?
a. Massage the uterus to decrease atony
MARKED A+
✔✔Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media.
An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What
instruction should the nurse emphasize concerning the installation of the antipyrine/
benzocaine otic solution?
a. Place the dropper on the upper outer ear canal and instill the medication slowly.
b. Warm the medication in the microwave for 10 seconds before instilling.
c. Keep the medication refrigerated between administrations.
d. Have the child lie with the ear up for one to two minutes after installation. - ✔✔d.
Have the child lie with the ear up for one to two minutes after installation.
✔✔An older adult male is admitted with complications related to chronic obstructive
pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion
and his weakness has increased over the past month. The nurse notes that he has
dependent edema in both lower legs. Based on these assessment findings, which
dietary instruction should the nurse provide?
a. Limit the intake of high calorie foods.
b. Eat meals at the same time daily.
c. Maintain a low protein diet.
d. Restrict daily fluid intake. - ✔✔Restrict daily fluid intake.
Rationale: the client is exhibiting signs of Cor pulmonale, a complication of COPD that
causes the right side of the heart to fail. Restricting fluid intake to 1000 to 2000 ml/day,
eating a high-calorie diet at small frequent meals with foods that are high in protein and
low in sodium can help relieve the edema and decrease workload on the right-side of
the heart.
✔✔The nurse inserts an indwelling urinary catheter as seen in the video what action
should the nurse take next?
a. Remove the catheter and insert into urethral opening
b. Observe for urine flow and then inflate the balloon.
c. Insert the catheter further and observe for discomfort.
d. Leave the catheter in place and obtain a sterile catheter. - ✔✔Leave the catheter in
place and obtain a sterile catheter.
✔✔A client with coronary artery disease who is experiencing syncopal episodes is
admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy.
Which intervention should the nurse delegate to the unlicensed assistive personnel
(UAP)?
, a. Prepare the skin for procedure.
b. Identify client's pulse points
c. Witness consent for procedure
d. Check telemetry monitoring - ✔✔Prepare the skin for procedure.
✔✔Following an outbreak of measles involving 5 students in an elementary school,
which action is most important for the school nurse to take?
a. Review the immunization records of all children in the elementary school
b. Report the measles outbreak to all community health organizations
c. Schedule a mobile public health vehicle to offer measles inoculations to unvaccinated
children.
d. Restrict unvaccinated children from attending school until measles outbreak is
resolved. - ✔✔Restrict unvaccinated children from attending school until measles
outbreak is resolved.
✔✔A preeclamptic client who delivered 24h ago remains in the labor and delivery
recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her
total input is limited to 125 ml per hour, and her urinary output for the last hour was 850
ml. What intervention should the nurse implement?
a. discontinue the magnesium sulfate immediately
b. Decrease the client's iv rate to 50 ml per hour
c. Continue with the plan of care for this client
d. Change the client's to NPO status - ✔✔c. Continue with the plan of care for this client
Rationale: continue with the plan. Diuresis in 24 to 48h after birth is a sign of
improvement in the preeclamptic client. As relaxation of arteriolar spasms occurs,
kidney perfusion increases. With improvement perfusion, fluid is drawn into the
intravascular bed from the interstitial tissue and then cleared by the kidneys
✔✔The nurse is planning care for a client who admits having suicidal thoughts. Which
client behavior indicates the highest risk for the client acting on these suicidal thoughts?
a. Express feelings of sadness and loneliness
b. Neglects personal hygiene and has no appetite
c. Lacks interest in the activity of the family and friends
d. Begin to show signs of improvement in affect - ✔✔Begin to show signs of
improvement in affect
✔✔When assessing a multigravida the first postpartum day, the nurse finds a moderate
amount of lochia rubra, with the uterus firm, and three fingerbreadths above the
umbilicus. What action should the nurse implement first?
a. Massage the uterus to decrease atony
