V3 EXIT HESI EXAM QUESTIONS AND
ANSWERS 100% CORRECT!!
,Which assessment should the home health nurse include during a routine home visit for
a client who was discharged home with a colostomy bag? - ANSWER Observe insertion
site
A client with arthritis has been receiving treatment with naproxen and now reports
ongoing stomach pain, increasing weakness and fatigue. Which lab test should the
nurse monitor? - ANSWER Hemoglobin
A client with influenza needs help in transferring to the bedside commode. The nurse
observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist
the client. Which action should the nurse take? - ANSWER Review the need for the
UAP to wear a face mask while in close contact with the client.
A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the
client's therapeutic response to this medication, which assessment should the nurse
obtain? - ANSWER Serum electrolytes.
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin
to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction
should the nurse provide to this mother? - ANSWER Withhold this dose.
The nurse is providing education to a client who experiences recurrent levels of
moderate anxiety to situations and perceived stress. In addition to information about
prescribed medication and administration, which instruction should the nurse include in
the teaching? - ANSWER Practice using muscle relaxation techniques.
The lower limit for normal plasma glucose levels during the first 72 hours after birth is 40
to 45 mg/dL (2.2 to 2.5 mmol/L). Hypoglycemia is most common in the macrocosmic or
LGA infant, but the nurse should monitor blood glucose levels in all infants of mothers
with known or suspected diabetes. Hypoglycemia most frequently occurs within the first
1 to 6 hours after birth. Signs of hypoglycemia include jitteriness, apnea, tachypnea,
hypotonia, decreased activity, and cyanosis. A Ballard score maturity assessment of 37
corresponds to 37 weeks gestation, which is a early term. Early term (37 0/7 through 38
6/7 weeks). Compared with full-term infants, early-term infants are at increased risk for
morbidity and mortality. - ANSWER Normal findings include acrocyanosis, soft
fontanelles, Mongolian spots, and Apgar scores of 7 to 10.
The nurse is reviewing the possible complications that can occur for an infant of a
diabetic mother. Choose the most likely options for the information missing from the
statement(s) by selecting from the lists of options provided. - ANSWER The nurse
, recognizes that the infant of a diabetic mother is at risk for hyperbilirubinemia,
respiratory distress syndrome, and cardiomyopathy
Glucose level immediately after birth and then at 30 min, 1 hour, 2 hours, 4 hours, 8 and
12 hours and if symptoms suggest hypoglycemla.
• Breastfeed Immediately once stable, then on
demand. If unstable, may feed breast milk via
orogastric tube.
• If two feeding attempts fall to increase the
glucose levels or if symptoms of hypoglycemia
develop, apply dextrose (sugar) gel Inside the
baby's cheek.
• If the above are ineffective, IV glucose should
be administered to maintain glucose levels
above 45 mg/dL (2.5 mmol/L). - ANSWER Monitor for Respiratory distress, contact
respiratory therapy for ABG and oxygen therapy, blood glucose level, keep in warmer
with Bilirubin lights, monitor temperature every 30 minutes, feed immediately
The nurse is reviewing lab work and nurses' notes to determine which actions to
take at this time. Which actions are appropriate for the nurse to take at this time? Select
all that apply. - ANSWER A Keep infant In warmer with bilirubin lights to maintain
temperature of 97.6°
B Inform the mother that the baby is stable enough to take out of the warmer
D Explain to the mother that the baby's respiratory rate needs to be below 60 1
E Observe for signs of respiratory distress and monitor oxygenation by pulse c
Day 1
1800: The client Is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother,
who was diagnosed with gestational dlabetes. Following a spontaneous vaginal birth,
she received Apgar scores of 7 at 1 min and 8 at 5 min. The client weighs 4036.97 g (8
Ibs. 9 oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous
fat. She is noted to be slightly jittery at 30 min of age. Axillary temperature 96° F (35.6°
C), pulse 140, respiratory rate 80. Blood glucose 35 mg/dL (1.9 mmol/L), bilirubin level 7
mg/dL (119.73 umol/L). Fontanelles soft, Mongolian spot noted on lower back, Ballard
maturity rating 37 weeks. - ANSWER Proactive lactation management, strategies,
support, and follow-up for late-preterm infants and some early term infants are important
components that affect breastfeeding success. Prophylactic phototherapy is often used
in preterm infants to prevent a significant increase in serum bilirubin levels. It is also
recommended that healthy late-preterm and term infants (23S weeks of gestation)
receive follow-up care and assessment of bilirubin within 3 days of discharge. Late
preterm infants of a diabetic mother need to be monitored more closely. Parents are
ANSWERS 100% CORRECT!!
,Which assessment should the home health nurse include during a routine home visit for
a client who was discharged home with a colostomy bag? - ANSWER Observe insertion
site
A client with arthritis has been receiving treatment with naproxen and now reports
ongoing stomach pain, increasing weakness and fatigue. Which lab test should the
nurse monitor? - ANSWER Hemoglobin
A client with influenza needs help in transferring to the bedside commode. The nurse
observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist
the client. Which action should the nurse take? - ANSWER Review the need for the
UAP to wear a face mask while in close contact with the client.
A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the
client's therapeutic response to this medication, which assessment should the nurse
obtain? - ANSWER Serum electrolytes.
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin
to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction
should the nurse provide to this mother? - ANSWER Withhold this dose.
The nurse is providing education to a client who experiences recurrent levels of
moderate anxiety to situations and perceived stress. In addition to information about
prescribed medication and administration, which instruction should the nurse include in
the teaching? - ANSWER Practice using muscle relaxation techniques.
The lower limit for normal plasma glucose levels during the first 72 hours after birth is 40
to 45 mg/dL (2.2 to 2.5 mmol/L). Hypoglycemia is most common in the macrocosmic or
LGA infant, but the nurse should monitor blood glucose levels in all infants of mothers
with known or suspected diabetes. Hypoglycemia most frequently occurs within the first
1 to 6 hours after birth. Signs of hypoglycemia include jitteriness, apnea, tachypnea,
hypotonia, decreased activity, and cyanosis. A Ballard score maturity assessment of 37
corresponds to 37 weeks gestation, which is a early term. Early term (37 0/7 through 38
6/7 weeks). Compared with full-term infants, early-term infants are at increased risk for
morbidity and mortality. - ANSWER Normal findings include acrocyanosis, soft
fontanelles, Mongolian spots, and Apgar scores of 7 to 10.
The nurse is reviewing the possible complications that can occur for an infant of a
diabetic mother. Choose the most likely options for the information missing from the
statement(s) by selecting from the lists of options provided. - ANSWER The nurse
, recognizes that the infant of a diabetic mother is at risk for hyperbilirubinemia,
respiratory distress syndrome, and cardiomyopathy
Glucose level immediately after birth and then at 30 min, 1 hour, 2 hours, 4 hours, 8 and
12 hours and if symptoms suggest hypoglycemla.
• Breastfeed Immediately once stable, then on
demand. If unstable, may feed breast milk via
orogastric tube.
• If two feeding attempts fall to increase the
glucose levels or if symptoms of hypoglycemia
develop, apply dextrose (sugar) gel Inside the
baby's cheek.
• If the above are ineffective, IV glucose should
be administered to maintain glucose levels
above 45 mg/dL (2.5 mmol/L). - ANSWER Monitor for Respiratory distress, contact
respiratory therapy for ABG and oxygen therapy, blood glucose level, keep in warmer
with Bilirubin lights, monitor temperature every 30 minutes, feed immediately
The nurse is reviewing lab work and nurses' notes to determine which actions to
take at this time. Which actions are appropriate for the nurse to take at this time? Select
all that apply. - ANSWER A Keep infant In warmer with bilirubin lights to maintain
temperature of 97.6°
B Inform the mother that the baby is stable enough to take out of the warmer
D Explain to the mother that the baby's respiratory rate needs to be below 60 1
E Observe for signs of respiratory distress and monitor oxygenation by pulse c
Day 1
1800: The client Is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother,
who was diagnosed with gestational dlabetes. Following a spontaneous vaginal birth,
she received Apgar scores of 7 at 1 min and 8 at 5 min. The client weighs 4036.97 g (8
Ibs. 9 oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous
fat. She is noted to be slightly jittery at 30 min of age. Axillary temperature 96° F (35.6°
C), pulse 140, respiratory rate 80. Blood glucose 35 mg/dL (1.9 mmol/L), bilirubin level 7
mg/dL (119.73 umol/L). Fontanelles soft, Mongolian spot noted on lower back, Ballard
maturity rating 37 weeks. - ANSWER Proactive lactation management, strategies,
support, and follow-up for late-preterm infants and some early term infants are important
components that affect breastfeeding success. Prophylactic phototherapy is often used
in preterm infants to prevent a significant increase in serum bilirubin levels. It is also
recommended that healthy late-preterm and term infants (23S weeks of gestation)
receive follow-up care and assessment of bilirubin within 3 days of discharge. Late
preterm infants of a diabetic mother need to be monitored more closely. Parents are
