RN HESI EXIT/HESI EXIT RN EXAM VERSION
6(V6) REAL/ACTUAL/AUTHENTIC EXAM
*18.A client is admitted with a severe asthma attack. For the last three
hours the
client has experienced increasing shortness of breath. Arterial blood gas
results are: ph 7.22; paco2 55mmhg; HCO3 25 meq/L (25 mmol/L). Which
intervention should the nurse implement?
a. Space care to provide periods of rest
b. Instruct client to purse lip breathe
c. Position client for maximum comfort
d. Administer PRN dose of albuterol - d. Administer PRN dose of albuterol
*34.After initiating a blood pressure cuff and releasing the valve, the nurse
hears silence followed by a Korotkoff sound. What action should the nurse
take next?
a. Note the presence of an auscultatory gap
b. Reinflate the cuff to a higher number
c. Reposition the stethoscope over the brachial artery
d. Continue with the blood pressure assessment - a. Note the presence of an
auscultatory gap
Choice A rationale:
Continue with the blood pressure assessment. Continuing with the blood
pressure assessment without addressing the observed auscultatory gap
could lead to an inaccurate reading. It's important to investigate and note
the presence of an auscultatory gap before proceeding with the assessment.
Choice B rationale:
,Reposition the stethoscope over the brachial artery. Repositioning the
stethoscope may not resolve the issue of hearing silence followed by a
Korotkoff sound. It is important to assess the situation further before making
adjustments.
Choice C rationale:
Reinflate the cuff to a higher number. Reinflating the cuff to a higher
number without addressing the auscultatory gap can result in an inaccurate
reading. The presence of an auscultatory gap should be noted and managed
appropriately.
Choice D rationale:
Note the presence of an auscultatory gap. This is the correct choice. An
auscultatory gap is a temporary disappearance of sounds during the blood
pressure measurement, and it may indicate underlying cardiovascular
issues. The nurse should note its presence, document it, and take
appropriate action if necessary.
*49.A mother brings her child, who has a history of asthma, to the
emergency
room. The child is wheezing and speaking one word between each breath.
The child is anxious, tachycardic, and has labored respirations. Which
assessment is most important for the nurse to obtain?
a. Frequency that the child uses a rescue inhaler during the week
b. Type of allergen exposure or trigger for the current episode
c. Type of inhaler the child typically uses on a regular basis
d. Last dose and type of rescue inhaler used by the child - a. Frequency that
the child uses a rescue inhaler during the week
Chegg:
d. Last dose and type of rescue inhaler used by the child
*60.The nurse is caring for a client who is receiving continuous ambulatory
,peritoneal dialysis (CAPD) and notes that the urine output flow is 100 ml less
than the input flow. Which action should the nurse implement first?
a. Irrigate the dialysis catheter
b. Check the client's blood pressure and serum bicarbonate
c. Change the client position
d. Continue to monitor and take an output with next exchange - d. Continue
to monitor and take an output with next exchange
*105. The nurse enters a client's room to administer oral medications and
finds an unlicensed assistive personnel (UAP) providing personal care to the
client, whose condition has obviously deteriorated. The client is lying in a
supine position and is weak, pale, and diaphoretic. What is the priority
nursing action?
a. Determine why the UAP did not notify the nurse of the change in the
client's condition
b. Advise the UAP stop providing care so the nurse can assess the client's
condition
c. Explain to the UAP that changes in the client's condition should be
reported immediately
d. Ask the UAP to position the client so the oral medications can be
administered - b. Advise the UAP stop providing care so the nurse can
assess the client's condition
*108. Which laboratory values are critical for the nurse to monitor for a
client
who is experiencing thyrotoxic crisis?
a. Blood in urine cultures
b. Glucose and calcium levels
, c. Renal and liver function tests
d. Electrolytes and hemoglobin - d. Electrolytes and hemoglobin
Other:
c. Renal and liver function tests
*114. A client with peptic ulcer disease receives a prescription for an
intermittent suction via a Salem Sump nasogastric tube (NGT). After
inserting
the NGT and obtaining coffee ground gastric contents, the nurse clamps the
NGT because the client must leave the unit for diagnostic studies. Upon
return to the unit, the client complaints of nausea. Which action should the
nurse implement first?
a. Connect the NGT to low intermittent suction
b. Irrigate the NGT with sterile normal saline
c. Provide oral suction using a Yank Auer tip
d. Administer a prescribed antiemetic agent - d. Administer a prescribed
antiemetic agent
Other:
a. Connect the NGT to low intermittent suction
*122. Which instruction regarding skin care should the nurse provide to a
client who is receiving radiation therapy for metastatic breast cancer?
a. Frequently apply moisturizers to prevent dry skin
b. Protect the site from getting wet during bathing
c. Use a sponge to debride the affected area
6(V6) REAL/ACTUAL/AUTHENTIC EXAM
*18.A client is admitted with a severe asthma attack. For the last three
hours the
client has experienced increasing shortness of breath. Arterial blood gas
results are: ph 7.22; paco2 55mmhg; HCO3 25 meq/L (25 mmol/L). Which
intervention should the nurse implement?
a. Space care to provide periods of rest
b. Instruct client to purse lip breathe
c. Position client for maximum comfort
d. Administer PRN dose of albuterol - d. Administer PRN dose of albuterol
*34.After initiating a blood pressure cuff and releasing the valve, the nurse
hears silence followed by a Korotkoff sound. What action should the nurse
take next?
a. Note the presence of an auscultatory gap
b. Reinflate the cuff to a higher number
c. Reposition the stethoscope over the brachial artery
d. Continue with the blood pressure assessment - a. Note the presence of an
auscultatory gap
Choice A rationale:
Continue with the blood pressure assessment. Continuing with the blood
pressure assessment without addressing the observed auscultatory gap
could lead to an inaccurate reading. It's important to investigate and note
the presence of an auscultatory gap before proceeding with the assessment.
Choice B rationale:
,Reposition the stethoscope over the brachial artery. Repositioning the
stethoscope may not resolve the issue of hearing silence followed by a
Korotkoff sound. It is important to assess the situation further before making
adjustments.
Choice C rationale:
Reinflate the cuff to a higher number. Reinflating the cuff to a higher
number without addressing the auscultatory gap can result in an inaccurate
reading. The presence of an auscultatory gap should be noted and managed
appropriately.
Choice D rationale:
Note the presence of an auscultatory gap. This is the correct choice. An
auscultatory gap is a temporary disappearance of sounds during the blood
pressure measurement, and it may indicate underlying cardiovascular
issues. The nurse should note its presence, document it, and take
appropriate action if necessary.
*49.A mother brings her child, who has a history of asthma, to the
emergency
room. The child is wheezing and speaking one word between each breath.
The child is anxious, tachycardic, and has labored respirations. Which
assessment is most important for the nurse to obtain?
a. Frequency that the child uses a rescue inhaler during the week
b. Type of allergen exposure or trigger for the current episode
c. Type of inhaler the child typically uses on a regular basis
d. Last dose and type of rescue inhaler used by the child - a. Frequency that
the child uses a rescue inhaler during the week
Chegg:
d. Last dose and type of rescue inhaler used by the child
*60.The nurse is caring for a client who is receiving continuous ambulatory
,peritoneal dialysis (CAPD) and notes that the urine output flow is 100 ml less
than the input flow. Which action should the nurse implement first?
a. Irrigate the dialysis catheter
b. Check the client's blood pressure and serum bicarbonate
c. Change the client position
d. Continue to monitor and take an output with next exchange - d. Continue
to monitor and take an output with next exchange
*105. The nurse enters a client's room to administer oral medications and
finds an unlicensed assistive personnel (UAP) providing personal care to the
client, whose condition has obviously deteriorated. The client is lying in a
supine position and is weak, pale, and diaphoretic. What is the priority
nursing action?
a. Determine why the UAP did not notify the nurse of the change in the
client's condition
b. Advise the UAP stop providing care so the nurse can assess the client's
condition
c. Explain to the UAP that changes in the client's condition should be
reported immediately
d. Ask the UAP to position the client so the oral medications can be
administered - b. Advise the UAP stop providing care so the nurse can
assess the client's condition
*108. Which laboratory values are critical for the nurse to monitor for a
client
who is experiencing thyrotoxic crisis?
a. Blood in urine cultures
b. Glucose and calcium levels
, c. Renal and liver function tests
d. Electrolytes and hemoglobin - d. Electrolytes and hemoglobin
Other:
c. Renal and liver function tests
*114. A client with peptic ulcer disease receives a prescription for an
intermittent suction via a Salem Sump nasogastric tube (NGT). After
inserting
the NGT and obtaining coffee ground gastric contents, the nurse clamps the
NGT because the client must leave the unit for diagnostic studies. Upon
return to the unit, the client complaints of nausea. Which action should the
nurse implement first?
a. Connect the NGT to low intermittent suction
b. Irrigate the NGT with sterile normal saline
c. Provide oral suction using a Yank Auer tip
d. Administer a prescribed antiemetic agent - d. Administer a prescribed
antiemetic agent
Other:
a. Connect the NGT to low intermittent suction
*122. Which instruction regarding skin care should the nurse provide to a
client who is receiving radiation therapy for metastatic breast cancer?
a. Frequently apply moisturizers to prevent dry skin
b. Protect the site from getting wet during bathing
c. Use a sponge to debride the affected area
