Nightingale College BSN 266
HESI 799 RN Exit Exam
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HESI COMPASS COMPREHENSIVE ... HESI exit exam 799 questions NCLEX EXAM PREVIEW HE
132 terms 798 terms 110 terms 125
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Terms in this set (798)
Following discharge teaching, a male client with Review with the client the need to avoid foods that are rich in milk and cream
duodenal ulcer tells the nurse the he will drink plenty of
dairy products, such as milk, to help coat and protect Rationale: Diets rich in milk and cream stimulate gastric acid secretion and
his ulcer. What is the best follow-up action by the should be avoided.
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.
,A male client with hypertension, who received new Stroke secondary to hemorrhage
antihypertensive prescriptions at his last visit returns to
the clinic two weeks later to evaluate his blood Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
pressure (BP). His BP is 158/106 and he admits that he hypertension.
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
The nurse observes an unlicensed assistive personnel Instruct the UAP to obtain soft blankets to secure to the side rails instead of
(UAP) positioning a newly admitted client who has a pillows
seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action Rationale: The nurse should instruct the UAP to pad the side rails with soft
should the nurse implement? blankest because the use of pillows could result in suffocation and would need
to be removed at the onset of the seizure. The nurse can delegate paddling the
side rails to the UAP
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.
d. Ask the UAP to use some of the pillows to prop the
client in a side lying position.
An adolescent with major depressive disorder has been Describes life without purpose
taking duloxetine (Cymbalta) for the past 12 days. Which
assessment finding requires immediate follow-up Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake
inhibitor that is known to increase the risk of suicidal thinking in adolescents
a. Describes life without purpose and young adults with major depressive disorder. B, C and D are side effects
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
A 60-year-old female client with a positive family Further evaluation involving surgery may be needed
history of ovarian cancer has developed an abdominal
mass and is being evaluated for possible ovarian Rationale: An abdominal mass in a client with a family history for ovarian cancer
cancer. Her Papanicolau (Pap) smear results are should be evaluated carefully
negative. What information should the nurse include in
the client's teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled
out
c. Pap smear evaluation should be continued every six
month
d. One additional negative pap smear in six months is
needed.
, A client who recently underwent a tracheostomy is Teach tracheal suctioning techniques
being prepared for discharge to home. Which
instructions is most important for the nurse to include in Rationale: Suctioning helps to clear secretions and maintain an open airway,
the discharge plan? which is critical.
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site.
In assessing an adult client with a partial rebreather Document the assessment data
mask, the nurse notes that the oxygen reservoir bag
does not deflate completely during inspiration and the Rational: reservoir bag should not deflate completely during inspiration and
client's respiratory rate is 14 breaths / minute. What the client's respiratory rate is within normal limits.
action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
During shift report, the central electrocardiogram (EKG) Respiratory apnea of 30 seconds
monitoring system alarms. Which client alarm should
the nurse investigate first? Rationale: The priority is the client whose alarm indicating respiratory apnea
that should be assessed first.
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes.
During a home visit, the nurse observed an elderly Check the client for lacerations or fractures
client with diabetes slip and fall. What action should the
nurse take first? Rationale: After the client falls, the nurse should immediately assess for the
possibility of injuries and provide first aid as needed
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level
At 0600 while admitting a woman for a schedule repeat Inform the anesthesia care provider
cesarean section (C-Section), the client tells the nurse
that she drank a cup a coffee at 0400 because she Rationale: Surgical preoperative instruction includes NPO after midnight the
wanted to avoid getting a headache. Which action day of surgery to decrease the risk of aspiration should vomiting occur during
should the nurse take first? 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.
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.
HESI 799 RN Exit Exam
118 studiers today 4.8 (106 reviews)
Play your way to mastery with fun games
Match Blocks Charms NEW
Students also studied
Flashcard sets Study guides
HESI COMPASS COMPREHENSIVE ... HESI exit exam 799 questions NCLEX EXAM PREVIEW HE
132 terms 798 terms 110 terms 125
georgemwaura2025 Preview quizchamp79 Preview kandykat1012 Preview
Terms in this set (798)
Following discharge teaching, a male client with Review with the client the need to avoid foods that are rich in milk and cream
duodenal ulcer tells the nurse the he will drink plenty of
dairy products, such as milk, to help coat and protect Rationale: Diets rich in milk and cream stimulate gastric acid secretion and
his ulcer. What is the best follow-up action by the should be avoided.
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.
,A male client with hypertension, who received new Stroke secondary to hemorrhage
antihypertensive prescriptions at his last visit returns to
the clinic two weeks later to evaluate his blood Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
pressure (BP). His BP is 158/106 and he admits that he hypertension.
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
The nurse observes an unlicensed assistive personnel Instruct the UAP to obtain soft blankets to secure to the side rails instead of
(UAP) positioning a newly admitted client who has a pillows
seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action Rationale: The nurse should instruct the UAP to pad the side rails with soft
should the nurse implement? blankest because the use of pillows could result in suffocation and would need
to be removed at the onset of the seizure. The nurse can delegate paddling the
side rails to the UAP
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.
d. Ask the UAP to use some of the pillows to prop the
client in a side lying position.
An adolescent with major depressive disorder has been Describes life without purpose
taking duloxetine (Cymbalta) for the past 12 days. Which
assessment finding requires immediate follow-up Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake
inhibitor that is known to increase the risk of suicidal thinking in adolescents
a. Describes life without purpose and young adults with major depressive disorder. B, C and D are side effects
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
A 60-year-old female client with a positive family Further evaluation involving surgery may be needed
history of ovarian cancer has developed an abdominal
mass and is being evaluated for possible ovarian Rationale: An abdominal mass in a client with a family history for ovarian cancer
cancer. Her Papanicolau (Pap) smear results are should be evaluated carefully
negative. What information should the nurse include in
the client's teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled
out
c. Pap smear evaluation should be continued every six
month
d. One additional negative pap smear in six months is
needed.
, A client who recently underwent a tracheostomy is Teach tracheal suctioning techniques
being prepared for discharge to home. Which
instructions is most important for the nurse to include in Rationale: Suctioning helps to clear secretions and maintain an open airway,
the discharge plan? which is critical.
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site.
In assessing an adult client with a partial rebreather Document the assessment data
mask, the nurse notes that the oxygen reservoir bag
does not deflate completely during inspiration and the Rational: reservoir bag should not deflate completely during inspiration and
client's respiratory rate is 14 breaths / minute. What the client's respiratory rate is within normal limits.
action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
During shift report, the central electrocardiogram (EKG) Respiratory apnea of 30 seconds
monitoring system alarms. Which client alarm should
the nurse investigate first? Rationale: The priority is the client whose alarm indicating respiratory apnea
that should be assessed first.
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes.
During a home visit, the nurse observed an elderly Check the client for lacerations or fractures
client with diabetes slip and fall. What action should the
nurse take first? Rationale: After the client falls, the nurse should immediately assess for the
possibility of injuries and provide first aid as needed
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level
At 0600 while admitting a woman for a schedule repeat Inform the anesthesia care provider
cesarean section (C-Section), the client tells the nurse
that she drank a cup a coffee at 0400 because she Rationale: Surgical preoperative instruction includes NPO after midnight the
wanted to avoid getting a headache. Which action day of surgery to decrease the risk of aspiration should vomiting occur during
should the nurse take first? 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.
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.
