HESI RN EXIT EXAM V7 COMPREHENSIVE TEST
PAPER QUESTIONS AND SOLUTIONS GRADED
A+
◉ The nurse manager of a skilled nursing (chronic care) unit is
instructing UAPs on ways to prevent complications of immobility.
Which action should be included in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift.
Answer: A
Rationale: Performing range-of-motion exercises is beneficial in
reducing contractures around joints. Options B, C, and D are all
potentially harmful practices that place the immobile client at risk of
complications.
◉ The nurse administered 10 mg of diazepam to the preoperative
client. What steps will the nurse take next? (Select all that apply.)
,A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom
Answer: B, C, D
Rationale: Diazepam is a common preoperative medication. Close
observation by placing the client close to the nurse's station is not
necessary. The medication has a sedative effect and the client should
not get out of bed, even with assistance. The remaining selections
are correct.
◉ A terminally ill client tells the nurse, "I am so tired and in so much
pain! Please help me to die." Which is the best response for the nurse
to provide?
A.
Administer the prescribed maximum dose of pain medication.
B.
,Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating
antidepressant therapy.
D.
Refer the client to the ethics committee of her local health care
facility.
Answer: B
Rationale: The nurse should first assess the client's feelings about
death and determine the extent to which this statement expresses
the client's true feelings. The client may need additional pain
management, but further assessment is needed before
implementing option A. Options C and D are both premature
interventions and should not be implemented until further
assessment is obtained.
◉ A nurse stops at a motor vehicle collision site to render aid until
the emergency personnel arrive and applies pressure to a groin
wound that is bleeding profusely. Later the client has to have the leg
amputated and sues the nurse for malpractice. Which statement
reflects the likely outcome for the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so
the nurse could lose the case.
B.
, The lawsuit may be settled out of court, but the nurse's license is
likely to be revoked.
C.
There will be no judgment against the nurse, whose actions are
protected under the Good Samaritan Act.
D.
The client will win because the four elements of negligence (duty,
breach, causation, and damages) can be proved.
Answer: C
Rationale: The Good Samaritan Act protects health care
professionals who practice in good faith and provide reasonable care
from malpractice claims, regardless of the client outcome. Although
the Patient's Bill of Rights protects clients, this nurse is protected by
the Good Samaritan Act. The state Board of Nursing has no reason to
revoke a registered nurse's license unless there was evidence that
actions taken in the emergency were not done in good faith or that
reasonable care was not provided. All four elements of malpractice
were not shown.
◉ An older client who had abdominal surgery 3 days earlier was
given a barbiturate for sleep and is now requesting to go to the
bathroom. What is the priority nursing action for this client?
A.
Assist the client to walk to the bathroom and do not leave the client
alone.
PAPER QUESTIONS AND SOLUTIONS GRADED
A+
◉ The nurse manager of a skilled nursing (chronic care) unit is
instructing UAPs on ways to prevent complications of immobility.
Which action should be included in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift.
Answer: A
Rationale: Performing range-of-motion exercises is beneficial in
reducing contractures around joints. Options B, C, and D are all
potentially harmful practices that place the immobile client at risk of
complications.
◉ The nurse administered 10 mg of diazepam to the preoperative
client. What steps will the nurse take next? (Select all that apply.)
,A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom
Answer: B, C, D
Rationale: Diazepam is a common preoperative medication. Close
observation by placing the client close to the nurse's station is not
necessary. The medication has a sedative effect and the client should
not get out of bed, even with assistance. The remaining selections
are correct.
◉ A terminally ill client tells the nurse, "I am so tired and in so much
pain! Please help me to die." Which is the best response for the nurse
to provide?
A.
Administer the prescribed maximum dose of pain medication.
B.
,Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating
antidepressant therapy.
D.
Refer the client to the ethics committee of her local health care
facility.
Answer: B
Rationale: The nurse should first assess the client's feelings about
death and determine the extent to which this statement expresses
the client's true feelings. The client may need additional pain
management, but further assessment is needed before
implementing option A. Options C and D are both premature
interventions and should not be implemented until further
assessment is obtained.
◉ A nurse stops at a motor vehicle collision site to render aid until
the emergency personnel arrive and applies pressure to a groin
wound that is bleeding profusely. Later the client has to have the leg
amputated and sues the nurse for malpractice. Which statement
reflects the likely outcome for the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so
the nurse could lose the case.
B.
, The lawsuit may be settled out of court, but the nurse's license is
likely to be revoked.
C.
There will be no judgment against the nurse, whose actions are
protected under the Good Samaritan Act.
D.
The client will win because the four elements of negligence (duty,
breach, causation, and damages) can be proved.
Answer: C
Rationale: The Good Samaritan Act protects health care
professionals who practice in good faith and provide reasonable care
from malpractice claims, regardless of the client outcome. Although
the Patient's Bill of Rights protects clients, this nurse is protected by
the Good Samaritan Act. The state Board of Nursing has no reason to
revoke a registered nurse's license unless there was evidence that
actions taken in the emergency were not done in good faith or that
reasonable care was not provided. All four elements of malpractice
were not shown.
◉ An older client who had abdominal surgery 3 days earlier was
given a barbiturate for sleep and is now requesting to go to the
bathroom. What is the priority nursing action for this client?
A.
Assist the client to walk to the bathroom and do not leave the client
alone.
