HESI RN EXIT EXAM 2021

HESI RN EXIT EXAM 2021 1. The nurse is reviewing medical prescriptions for newly admitted clients. It would be a priority for the nurse to follow up with the physician if a client with (a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene) prescribed (b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen) (d) sensitivity to Penicillin is prescribed Zithromax (azithromycin) 2. The nurse should intervene if the nurse notes a staff member (a) obtaining a clients consent prior to their operative procedure after receiving Ativan (lorazepam) (b) placing a client on the affected side following surgical repair of a retinal detachment (c) handling a wet cast with the palms of the hands (d) using a broad base of support while transferring a client 3. The community health nurse is caring for the following clients. It would be a priority for the nurse to initiate a multidisciplinary conference for the client who is (a) 12 years old with Autism who is starting a new school and recently had a URI (upper respiratory tract infection) (b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent Hemoglobin A1c of 13% (c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and employed as a mail carrier (d) 70 years old, has schizophrenia, lives alone and reports hearing non threatening voices. 4. The nurse from the postpartum unit has been temporarily assigned to the medical surgical unit. It would be most appropriate to assign this nurse to the client who* (a) has returned from right total hip replacement surgery four hours ago (b) is being observed for increased intracranial pressure (c) had surgery two hours ago to remove the appendix (d) is two weeks post partum being maintained on a mechanical ventilator for respiratory failure 1 5. The nurse in a well baby clinic has assessed several children today. It would be a priority for the nurse to suggest follow up for the child who is (a) 2 months old with a positive babinski refl ex (b) 5 months old and does not hold their own bottle (c) 10 months old who cries around strangers (d) 18 months old who needs support while ambulating 6. The nurse is caring for a mechanically ventilated client who was declared brain dead. An Advance Directive is not documented on the medical record. It would be most appropriate to obtain consent for organ donation from the (a) client’s primary care provider (b) client’s nurse manager (c) closest living family member (d) hospital’s ethics committee 7. The nurse has received report on four clients. The nurse should fi rst assess the client who has* (a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90% (b) Parkinson’s Disease and is demanding to leave the hospital against medical advice (AMA) (c) been admitted with suspected Guillian-Barre´ Syndrome and has begun plasmapheresis therapy (d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) 8. It would be appropriate to assign which of these tasks to the CNA? (a) Feeding a client who is experiencing dysphagia (b) One-on-one client observation for safety (c) Removal of an indwelling catheter (d) Performing a simple dressing change 9. The nurse should intervene if a staff member is observed (a) discussing a client’s diagnosis with visiting family members (b) collaborating with another nurse to review a prescription for blood transfusion (c) interrupting other staff members discussing a client in the cafeteria (d) reviewing a clients lab values with the nutritionist 2 10. The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse would be correct to include which of the following examples? (a) Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is false imprisonment (b) Telling a client that you will put in a feeding tube if the client does not eat is an example of battery (c) Telling a client with bipolar disorder who is suicidal that they have a right to refuse to take their medications is an example of malpractice (d) Placing hands on a client who says “do not touch me” is an example of assault 11. The nurse from the pediatric unit has been temporarily assigned to the Emergency Department. It would be most appropriate to assign that nurse to the client who* (a) reports epigastric pain that “feels like indigestion” (b) has back pain and a pulsating abdominal mass (c) is HIV+ reporting vomiting and diarrhea (d) presents with lower abdominal pain and is six weeks pregnant 12. Four clients recently returned to the unit following invasive diagnostic testing. The nurse should immediately intervene if one of the clients (a) reports blood tinged sputum following a bronchoscopy (b) has decreased abdominal girth following paracentesis (c) reports a headache following a lumbar puncture (d) is observed flexing and extending the legs two hours after cardiac catheterization 13. The nurse is made aware of the following situations. The nurse should fi rst check the client who (a) had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours after the indwelling catheter is removed (b) has cervical traction and is moving the legs by fl exing and extending the feet (c) has Alzheimer’s disease (stage 1) and was returned to the room after being found wandering in the hallway (d) has a history of partial seizures and is sitting in the bed picking at the clothing and smacking the lips 14. The nurse in a community health clinic is talking with the parent of a child with Celiac Disease. Which of the following statements would require follow-up by the nurse for additional teaching? 15. (a) “This weekend we are going to a seafood restaurant.” (b) “I can feed my child oatmeal and eggs for breakfast.” (c) “My child loves to eat rice and chicken for dinner.” (d) “Last night we ate fi sh with corn for dinner.” 16. The charge nurse is observing a Licensed Practical Nurse (LPN) performing care for assigned clients. Follow up will be required if the LPN*: (a) assesses a client’s apical pulse before administering Digoxin (lanoxin) (b) elevates the client’s stump on a pillow eight hours after amputation (c) dons a clean glove on the dominant hand before tracheal suctioning (d) positions a client on the operative side following a pneumonectomy 17. The nurse at a health promotion fair has taught a group of parents about car seat and seat belt safety. Which of the following statements, if made by the parent, would indicate a correct understanding of the information given? (a) “I will place my newborn infant in a rear facing car seat in the middle of the rear seat.” (b) “I will wear a lap seat belt high on my belly since I am 8 months pregnant.” (c) “I can use a front-facing car seat once my baby weighs 15 pounds.” (d) “I can allow my six-year-old to use a seat belt in the front passenger seat.” 18. The nurse is caring for a client being treated for Vancomycin Resistant Enterococcus (VRE). The nurse should place the client on (a) contact precautions (b) droplet precautions (c) protective precautions (d) airborne precautions 19. The nurse is caring for a client with a Vancomycin Resistant Enterococcus (VRE) wound infection. Which of the following actions would be appropriate for the nurse to take? (a) Wear a particulate respirator mask when providing wound care (b) Instruct visitors not to bring fl owers into the client’s room (c) Place the client in a private room with negative air pressure (d) Wear a disposable gown when changing the client’s dressing 20. The nurse should initiate protective precautions for a client who has a (a) Red Blood Cell Count (RBC) of 3,900/mm3 4 (b) Platelet count of 400,000μ/L (c) Hemoglobin (Hgb) 9.0 g/dl (d) White Blood Cell Count (WBC) 2,500/mm3 21. The nurse has provided health promotion teaching for a group of clients who were recently diagnosed with the Human immunodefi ciency virus (HIV). Which statement, if made by one of the clients, would require further teaching? (a) “I am glad that I can still clean my parakeet’s cage.” (b) “I will not go to the parade this weekend.” (c) “I will increase protein in my diet.” (d) “I will miss not being able to work in my garden.” 22. The nurse in the emergency department is caring for clients admitted following a rescue from a burning bus. The nurse should fi rst see the client who (a) has the tibia bone protruding through the skin and is in severe pain (b) has third degree burns of the left foot and is crying (c) is unconscious, pulseless, and has dilated pupils (d) has soot on the face and the nares and is coughing 23. A nurse is observing a newly-hired nurse provide care for assigned clients. The nurse should follow up if the newly-hired nurse is observed (a) wearing gloves when taking the blood pressure of a client with disseminated varicella zoster (b) cleansing the wound from the outer surface to the inner surface for a client whose wound is infected with a multi-drug resistant organism (c) washing the hands with the fi ngertips pointed downward before providing care for a client on protective precautions (d) removing the gloves before removing the gown when leaving a room of a client who is on contact precautions 24. The nurse is caring for a client who has been diagnosed with rheumatoid arthritis. The nurse should anticipate that the client will initially be prescribed (a) Disease-modifying rheumatic agents (DMARDs) (b) Nonselective anti-infl ammatory drugs (NSAIDs) (c) Long-term corticosteroids (d) Biologic Response Modifi ers 25. The nurse is assessing a 2-month-old-infant at a well baby clinic. The nurse should anticipate the infant should (a) roll from prone to back (b) have no head lag (c) smile socially (d) have no tonic neck refl ex 26. The nurse is teaching a class on infant nutrition. The nurse should instruct parents to introduce (a) fruit juices at 3 months (b) honey sweetened water at 6 months (c) pureed chicken at 7 months (d) whole milk at 9 months 27. The nurse is caring for a 7-year-old who has thrombocytopenia and is on protective precautions. Which of the following would be an appropriate toy for the nurse to provide to the client? (a) Finger paints and paper (b) A rubber ball and bat (c) A board game (d) A stuffed toy 28. The nurse on a pediatric unit has been informed that the following clients are being admitted. The nurse should fi rst plan to assess the client who is* (a) 2 years old, has a temperature of 100.8 F and a blood pressure of 68/44 (b) 4 years old with a history of asthma and has a peak expiratory fl ow rate (PERF) of 81% (c) 5 years old, has a fracture of the tibia and is reporting pain rated 7 on a pain scale of 0 (no pain) to 10 (severe pain) (d) 7 years old with ulcerative colitis and has had 15 blood tinged stools today 29. The nurse is providing discharge instructions to the parents of an infant who has a cleft lip. The nurse should instruct the parents to (a) place the infant in a prone position after each feeding (b) encourage the parents to provide the infant rest periods during feedings (c) regularly offer the infant a pacifi er to enhance the sucking refl ex (d) elevate the child’s head forty fi ve degrees during feeding 30. The nurse is assessing a 3-year-old during a well-child visit. During the visit the boy says to his mother, “Mommy, I love you. I’m going to marry you.” The nurse should (a) suggest to the mother not to encourage these types of statements (b) explain to the child that he will not be able to marry his mother even though he loves her (c) tell the mother that this statement is appropriate for his stage of development (d) recommend that the mother provide more opportunities for her son to play with other 3-year-old boys 31. The nurse is assessing a child with coarctation of the aorta. Which of the following would be an expected fi nding? (a) diminished blood pressure in the upper extremities (b) excessive weight gain (c) high pitched murmur (d) absence of femoral pulses 32. The nurse is caring for a child with an acyanotic heart defect. Which of the following would be an expected fi nding. Select all that apply. (a) poor suck refl ex (b) tachycardia (c) increased respiratory rate (d) bradycardia (e) fainting spells (f) delayed growth and development 33. The nurse is teaching a new mother about immunizations. Which of the following should the nurse include in the teaching? (a) “Your baby should wait six months to receive any immunizations since the baby was born preterm.” (b) “Your baby will receive the fi rst hepatitis B vaccine after one year of age.” (c) “Acellular Pertussis vaccine has less side effects than whole-cell pertussis vaccine.” (d) The Haemophilus Infl uenza Type b (HIB) is given annually to protect against the fl u.” 7 34. The mother of an infant tells the nurse that the baby has not been tolerating feedings lately and she noticed an olive-shaped mass in the infant’s abdomen. The nurse recognizes that this could be an expected fi nding if the infant has (a) intussusception (b) Hirschsprung’s disease (c) umbilical hernia (d) pyloric stenosis 35. The nurse is teaching a group of parents about the expected growth and development of three-year-old children. The nurse should include that a three-year-old should (a) discriminate between fantasy and reality (b) ride a tricycle independently (c) have a vocabulary of 7,000 words (d) play in a group of two or three with one being the leader 36. The nurse and the nursing assistant are caring for a group of clients. Which of the following client care activities should the nurse assign to the nursing assistant? Select all that apply. (a) reinforcing the dressing of a client who has a decubitus ulcer (b) monitoring the vital signs of a client who had a myocardial