,
,PAGE: 03
HESI EXIT V1
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.
Correct Answer: 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.
Following discharge teaching, a male client with duodenal ulcer tells the nurse
the he will drink plenty of dairy products, such as milk, to help coat and protect
his ulcer. What is the best follow-up action by the nurse?
a. Remind the client that it is also important to switch to decaffeinated coffee
and tea.
b. Suggest that the client also plan to eat frequent small meals to reduce
discomfort
c. Review with the client the need to avoid foods that are rich in milk and cream.
d. Reinforce this teaching by asking the client to list a dairy food that he might
select.
Correct Answer: Review with the client the need to avoid foods that are rich in
milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and
should be avoided.
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and
S2 heart sounds. To determine if an S3 heart sound is present, what action
should the nurse take first
, a. Side the stethoscope across the sternum.
b. Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d. Observe the cardiac telemetry monitor
Correct Answer: Listen with the bell at the same location
Rationale: The nurse uses the bell of the stethoscope to hear low-pitched
sounds such as S3 and
S4. The nurse listens at the same site using the diaphragm the diaphragm and
bell before moving systematically to the next sites.
A male client with hypertension, who received new antihypertensive
prescriptions at his last visit returns to the clinic two weeks later to evaluate his
blood pressure (BP). His BP is 158/106 and he admits that he has not been
taking the prescribed medication because the drugs make him "feel bad". In
explaining the need for hypertension control, the nurse should stress that an
elevated BP places the client at risk for which pathophysiological condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
Correct Answer: Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse
implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
c. Assume responsibility for placing the pillows while the UAP completes
another task.
,PAGE: 03
HESI EXIT V1
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.
Correct Answer: 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.
Following discharge teaching, a male client with duodenal ulcer tells the nurse
the he will drink plenty of dairy products, such as milk, to help coat and protect
his ulcer. What is the best follow-up action by the nurse?
a. Remind the client that it is also important to switch to decaffeinated coffee
and tea.
b. Suggest that the client also plan to eat frequent small meals to reduce
discomfort
c. Review with the client the need to avoid foods that are rich in milk and cream.
d. Reinforce this teaching by asking the client to list a dairy food that he might
select.
Correct Answer: Review with the client the need to avoid foods that are rich in
milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and
should be avoided.
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and
S2 heart sounds. To determine if an S3 heart sound is present, what action
should the nurse take first
, a. Side the stethoscope across the sternum.
b. Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d. Observe the cardiac telemetry monitor
Correct Answer: Listen with the bell at the same location
Rationale: The nurse uses the bell of the stethoscope to hear low-pitched
sounds such as S3 and
S4. The nurse listens at the same site using the diaphragm the diaphragm and
bell before moving systematically to the next sites.
A male client with hypertension, who received new antihypertensive
prescriptions at his last visit returns to the clinic two weeks later to evaluate his
blood pressure (BP). His BP is 158/106 and he admits that he has not been
taking the prescribed medication because the drugs make him "feel bad". In
explaining the need for hypertension control, the nurse should stress that an
elevated BP places the client at risk for which pathophysiological condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
Correct Answer: Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse
implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
c. Assume responsibility for placing the pillows while the UAP completes
another task.
