ALL HESI EXIT SET 2 UPDATED ACTUAL
QUESTIONS AND CORRECT ANSWERS
◉ An emergency department nurse is told that a client with carbon
monoxide poisoning resulting from a suicide attempt is being
brought to the hospital by emergency medical services. Which
intervention will the nurse carry out as a priority upon arrival of the
client?
Administering 100% oxygen
Having a crisis counselor available
Instituting suicide precautions for the client
Obtaining blood for determination of the client's carboxyhemoglobin
level. Answer: Administering 100% oxygen
Rationale: With a client with carbon monoxide poisoning, the
priority is to treat the client with inhalation of 100% oxygen to
shorten the half-life of carbon monoxide to around an hour.
Hyperbaric oxygen may be required to reduce the half-life to
minutes by forcing the carbon monoxide off the hemoglobin
molecule. Because the poisoning occurred as a result of a suicide
attempt, a crisis counselor should be consulted, but this is not the
,priority. Suicide precautions should be instituted once emergency
interventions have been completed and the client has been admitted
to the hospital. The diagnosis is confirmed with a measurement of
the carboxyhemoglobin level in the client's blood. Obtaining a blood
specimen to measure the carboxyhemoglobin level is a priority;
however, the nurse would immediately administer 100% oxygen to
the client.
◉ A nurse is caring for a client with sarcoidosis. The client is upset
because he has missed work and worried about how he will care
financially for his wife and three small children. On the basis of the
client's concern, which problem does the nurse identify?
Anxiety
Powerlessness
Disruption of thought processes
Inability to maintain health. Answer: Anxiety
Rationale: Anxiety is a vague, uneasy feeling of apprehension. Some
related factors include a threat or perceived threat to physical or
emotional integrity or self-concept, changes in function in one's role,
and threats to or changes in socioeconomic status. The client
experiencing powerlessness expresses feelings of having no control
over a situation or outcome. Disruption of thought processes
involves disturbance of cognitive abilities or thought. Inability to
,maintain health is being incapable of seeking out help needed to
maintain health.
◉ A nurse, performing an assessment of a client who has been
admitted to the hospital with suspected silicosis, is gathering both
subjective and objective data. Which question by the nurse would
elicit data specific to the cause of this disorder?
"Do you chew tobacco?"
"Do you smoke cigarettes?"
"Have you ever worked in a mine?"
"Are you frequently exposed to paint products?". Answer: "Have you
ever worked in a mine?"
Rationale: Silicosis is a chronic fibrotic disease of the lungs caused
by the inhalation of free crystalline silica dust over a long period.
Mining and quarrying are each associated with a high incidence of
silicosis. Hazardous exposure to silica dust also occurs in foundry
work, tunneling, sandblasting, pottery-making, stone masonry, and
the manufacture of glass, tile, and bricks. The finely ground silica
used in soaps, polishes, and filters also presents a risk. The
assessment questions noted in the other options are unrelated to the
cause of silicosis.
, ◉ A primary health care provider prescribes a dose of morphine
sulfate 2.5 mg stat to be administered intravenously to a client in
pain. The nurse preparing the medication notes that the label on the
vial of morphine sulfate solution for injection reads "4 mg/mL." How
many milliliters (mL) must the nurse draw into a syringe for
administration to the client? Type the answer in the space provided.
_____ mL. Answer: 0.625
◉ A client undergoing therapy with carbidopa/levodopa calls the
nurse at the clinic and reports that his urine has become darker
since he started taking the medication. What should the nurse tell
the client?
To call his primary health care provider
That he needs to drink more fluids
That this is an occasional side effect of the medication
That this may be a sign/symptom of developing toxicity of the
medication. Answer: That this is an occasional side effect of the
medication
Rationale: Carbidopa/levodopa, an antiparkinson agent, may cause
darkening of the urine or sweat. The client should be reassured that
this is a harmless side effect of the medication and that the
medication's use should be continued. Although fluid intake is
important, telling the client that he needs to drink more fluid is
incorrect and unnecessary. Telling the client that the darkening of
QUESTIONS AND CORRECT ANSWERS
◉ An emergency department nurse is told that a client with carbon
monoxide poisoning resulting from a suicide attempt is being
brought to the hospital by emergency medical services. Which
intervention will the nurse carry out as a priority upon arrival of the
client?
Administering 100% oxygen
Having a crisis counselor available
Instituting suicide precautions for the client
Obtaining blood for determination of the client's carboxyhemoglobin
level. Answer: Administering 100% oxygen
Rationale: With a client with carbon monoxide poisoning, the
priority is to treat the client with inhalation of 100% oxygen to
shorten the half-life of carbon monoxide to around an hour.
Hyperbaric oxygen may be required to reduce the half-life to
minutes by forcing the carbon monoxide off the hemoglobin
molecule. Because the poisoning occurred as a result of a suicide
attempt, a crisis counselor should be consulted, but this is not the
,priority. Suicide precautions should be instituted once emergency
interventions have been completed and the client has been admitted
to the hospital. The diagnosis is confirmed with a measurement of
the carboxyhemoglobin level in the client's blood. Obtaining a blood
specimen to measure the carboxyhemoglobin level is a priority;
however, the nurse would immediately administer 100% oxygen to
the client.
◉ A nurse is caring for a client with sarcoidosis. The client is upset
because he has missed work and worried about how he will care
financially for his wife and three small children. On the basis of the
client's concern, which problem does the nurse identify?
Anxiety
Powerlessness
Disruption of thought processes
Inability to maintain health. Answer: Anxiety
Rationale: Anxiety is a vague, uneasy feeling of apprehension. Some
related factors include a threat or perceived threat to physical or
emotional integrity or self-concept, changes in function in one's role,
and threats to or changes in socioeconomic status. The client
experiencing powerlessness expresses feelings of having no control
over a situation or outcome. Disruption of thought processes
involves disturbance of cognitive abilities or thought. Inability to
,maintain health is being incapable of seeking out help needed to
maintain health.
◉ A nurse, performing an assessment of a client who has been
admitted to the hospital with suspected silicosis, is gathering both
subjective and objective data. Which question by the nurse would
elicit data specific to the cause of this disorder?
"Do you chew tobacco?"
"Do you smoke cigarettes?"
"Have you ever worked in a mine?"
"Are you frequently exposed to paint products?". Answer: "Have you
ever worked in a mine?"
Rationale: Silicosis is a chronic fibrotic disease of the lungs caused
by the inhalation of free crystalline silica dust over a long period.
Mining and quarrying are each associated with a high incidence of
silicosis. Hazardous exposure to silica dust also occurs in foundry
work, tunneling, sandblasting, pottery-making, stone masonry, and
the manufacture of glass, tile, and bricks. The finely ground silica
used in soaps, polishes, and filters also presents a risk. The
assessment questions noted in the other options are unrelated to the
cause of silicosis.
, ◉ A primary health care provider prescribes a dose of morphine
sulfate 2.5 mg stat to be administered intravenously to a client in
pain. The nurse preparing the medication notes that the label on the
vial of morphine sulfate solution for injection reads "4 mg/mL." How
many milliliters (mL) must the nurse draw into a syringe for
administration to the client? Type the answer in the space provided.
_____ mL. Answer: 0.625
◉ A client undergoing therapy with carbidopa/levodopa calls the
nurse at the clinic and reports that his urine has become darker
since he started taking the medication. What should the nurse tell
the client?
To call his primary health care provider
That he needs to drink more fluids
That this is an occasional side effect of the medication
That this may be a sign/symptom of developing toxicity of the
medication. Answer: That this is an occasional side effect of the
medication
Rationale: Carbidopa/levodopa, an antiparkinson agent, may cause
darkening of the urine or sweat. The client should be reassured that
this is a harmless side effect of the medication and that the
medication's use should be continued. Although fluid intake is
important, telling the client that he needs to drink more fluid is
incorrect and unnecessary. Telling the client that the darkening of
