HESI EXIT QUESTIONS AND ANSWERS

HESI EXIT QUESTIONS AND ANSWERS 1. The nurse assesses a client one hour after starting a transfusion of packed RBC and determines that there are no indicators of a transfusion reaction. What instruction should the nurse provide the unlicensed assistive personnel UAP who is working with the nurse? a. Notify the nurse when the transfusion has finished, so further client assessment can be done b. Monitor the client carefully for the next three hours and report the onset of the reaction immediately c. Continue to measure the client’s vital signs every thirty minutes until transfusion is complete d. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion 2. An older client is brought to the clinic for appointment by a grandson. The client is withdrawn and allows the grandson to answer the nurse’s questions. The nurse observes the grandson makes frowning facial expressions and shakes his head sighing when speaking to the client. Which action the nurse take next? a. Ask the client if an assisted living facility has been considered b. Request social services to make a home visit c. Interview the client privately without the family member present d. Complete a neurological and musculoskeletal assessment 3. The mother of an adolescent female tells the clinic nurse that after every meal her daughter goes to the bathroom, locks the door and vomits. Which physical assessment should the nurse implement if bulimia is suspected? a. Skin of palms of the hand b. Current height and weight c. Condition of tooth enamel d. Length of the last menses 4. A new nurse preparing to irrigate an intravenous catheter is attaching a 24-guage needle. Which action should the charge nurse implement? a. Prompt the nurse to apply povidone to the site b. Suggest the nurse use a 20-guage needle c. Direct the nurse to change the IV tubing d. Instruct the nurse to remove the needle 5. After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? SATA a. Location of the initial IV site b. Swollen lymph nodes in the groin c. White blood cell count (WBC) d. Core body temperature e. Red blood cell count (RBC)