RN HESI EXIT EXAM V3 COMPREHENSIVE TEST
PAPER QUESTIONS AND SOLUTIONS GRADED
A+
◉ A nurse is assigned to care for a close friend in the hospital
setting. Which action should the nurse take first when given the
assignment?
A.
Notify the friend that all medical information will be kept
confidential.
B.
Explain the relationship to the charge nurse and ask for
reassignment.
C.
Approach the client and ask if the assignment is uncomfortable.
D.
Accept the assignment but protect the client's confidentiality.
Answer: B
Rationale: Caring for a close friend can violate boundaries for nurses
and should be avoided when possible (B). If the assignment is
unavoidable (there are no other nurses to care for the client) then C,
A, and D should be addressed.
,◉ The nurse selects the best site for insertion of an IV catheter in
the client's right arm. Which documentation should the nurse use to
identify placement of the IV access?
A.
Left brachial vein
B.
Right cephalic vein
C.
Dorsal side of the right wrist
D.
Right upper extremity
Answer: B
Rationale: The cephalic vein is large and superficial and identifies
the anatomic name of the vein that is accessed, which should be
included in the documentation. The basilic vein of the arm is used
for IV access, not the brachial vein, which is too deep to be accessed
for IV infusion. Although veins on the dorsal side of the right wrist
are visible, they are fragile and using them would be painful, so they
are not recommended for IV access. Option D is not specific enough
for documenting the location of the IV access.
◉ The nurse transcribes the postoperative prescriptions for a client
who returns to the unit following surgery and notes that an
antihypertensive medication that was prescribed preoperatively is
not listed. Which action should the nurse take?
,A.
Consult with the pharmacist about the need to continue the
medication.
B.
Administer the antihypertensive medication as prescribed
preoperatively.
C.
Withhold the medication until the client is fully alert and vital signs
are stable.
D.
Contact the health care provider to renew the prescription for the
medication.
Answer: D
Rationale: Medications prescribed preoperatively must be renewed
postoperatively, so the nurse should contact the health care provider
if the antihypertensive medication is not included in the
postoperative prescriptions. The pharmacist does not prescribe
medications or renew prescriptions. The nurse must have a current
prescription before administering any medications.
◉ When emptying 350 mL of pale yellow urine from a client's urinal,
the nurse notes that this is the first time the client has voided in 4
hours. Which action should the nurse take next?
A.
Record the amount on the client's fluid output record.
, B.
Encourage the client to increase oral fluid intake.
C.
Notify the health care provider of the findings.
D.
Palpate the client's bladder for distention.
Answer: A
Rationale: The amount and appearance of the client's urine output is
within normal limits, so the nurse should record the output, but no
additional action is needed.
◉ The client states to the nurse, "This medication makes my mouth
so dry." What are the nurse's suggestions to quench the client's
thirst? (Select all that apply.)
A.
Drink 2, 8 ounce glasses of lemon-lime soda every day.
B.
Infuse your water with fresh citrus fruits to quench your thirst.
C.
Freeze strawberries and water together in popsicle mold.
D.
Add ginger ale to your daily glass of juice every day.
E.
PAPER QUESTIONS AND SOLUTIONS GRADED
A+
◉ A nurse is assigned to care for a close friend in the hospital
setting. Which action should the nurse take first when given the
assignment?
A.
Notify the friend that all medical information will be kept
confidential.
B.
Explain the relationship to the charge nurse and ask for
reassignment.
C.
Approach the client and ask if the assignment is uncomfortable.
D.
Accept the assignment but protect the client's confidentiality.
Answer: B
Rationale: Caring for a close friend can violate boundaries for nurses
and should be avoided when possible (B). If the assignment is
unavoidable (there are no other nurses to care for the client) then C,
A, and D should be addressed.
,◉ The nurse selects the best site for insertion of an IV catheter in
the client's right arm. Which documentation should the nurse use to
identify placement of the IV access?
A.
Left brachial vein
B.
Right cephalic vein
C.
Dorsal side of the right wrist
D.
Right upper extremity
Answer: B
Rationale: The cephalic vein is large and superficial and identifies
the anatomic name of the vein that is accessed, which should be
included in the documentation. The basilic vein of the arm is used
for IV access, not the brachial vein, which is too deep to be accessed
for IV infusion. Although veins on the dorsal side of the right wrist
are visible, they are fragile and using them would be painful, so they
are not recommended for IV access. Option D is not specific enough
for documenting the location of the IV access.
◉ The nurse transcribes the postoperative prescriptions for a client
who returns to the unit following surgery and notes that an
antihypertensive medication that was prescribed preoperatively is
not listed. Which action should the nurse take?
,A.
Consult with the pharmacist about the need to continue the
medication.
B.
Administer the antihypertensive medication as prescribed
preoperatively.
C.
Withhold the medication until the client is fully alert and vital signs
are stable.
D.
Contact the health care provider to renew the prescription for the
medication.
Answer: D
Rationale: Medications prescribed preoperatively must be renewed
postoperatively, so the nurse should contact the health care provider
if the antihypertensive medication is not included in the
postoperative prescriptions. The pharmacist does not prescribe
medications or renew prescriptions. The nurse must have a current
prescription before administering any medications.
◉ When emptying 350 mL of pale yellow urine from a client's urinal,
the nurse notes that this is the first time the client has voided in 4
hours. Which action should the nurse take next?
A.
Record the amount on the client's fluid output record.
, B.
Encourage the client to increase oral fluid intake.
C.
Notify the health care provider of the findings.
D.
Palpate the client's bladder for distention.
Answer: A
Rationale: The amount and appearance of the client's urine output is
within normal limits, so the nurse should record the output, but no
additional action is needed.
◉ The client states to the nurse, "This medication makes my mouth
so dry." What are the nurse's suggestions to quench the client's
thirst? (Select all that apply.)
A.
Drink 2, 8 ounce glasses of lemon-lime soda every day.
B.
Infuse your water with fresh citrus fruits to quench your thirst.
C.
Freeze strawberries and water together in popsicle mold.
D.
Add ginger ale to your daily glass of juice every day.
E.
