2021 HESI EXIT EXAM 61 QUESTIONS AND ANSWERS GRADED A

1. The nurse applies a blood pressure cuff around a client’s left thigh. To measure the client’s blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the loication on one of the images.) “On left thigh with arrow pointing to inner thigh” 2. Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)? An elderly female client with cancer whose children who are trying to decide whether to change to palliative care measures or continue disease control 3. When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur? • Resume normal physical activity • Drink electrolyte fluid replacement • Give a dose of regular insulin per sliding scale • Measure urinary output over 24 hours. 4. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.) • Recognize signs and symptoms of hypoglycemia. • Report persist polyuria to the healthcare provider. • Take Glucophage with the morning and evening meal. 5. A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? • Collect a clean catch urine specimen. • Instruct the client to empty the bladder. • Obtain vital signs and breath sounds. • No specific nursing action is required 6. In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement? • Ensure that no dependent loops are present in the tubing. 7. A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the HCP has prescribed all these medications. Which information should the nurse include when responding to this client? One of the medications is used to anesthetized the corneal surface. The iris must be paralyzed during surgery to prevent it from reacting to light. A medication is used to induce sleep during procedure. 8. A nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse request, which action is best for the charge nurse to take? • Since treatment is completed, assign the nurse to the route RN responsibilities • Ask to meet with impaired nurse’s therapist before allowing her back on the unit. • Allow the impaired nurse to return to work and monitor medication administration • Meet with staff to assess their feelings about the impaired nurse’s return to the unit. 9. Based on the information provided in this client’s medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.) a. Continue to monitor the progress of labor.??? 10. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement? a. Document the extend of the bruising in the medical record 11. The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection? a. Moderate amount of foul-smelling lochia. 12. What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? a. Initiate the dosage lockout mechanism on the PCA pump b. Instruct the client to use the medication before the pain becomes severe c. Assess the abdomen for bowel sounds. d. Assess the client ability to use a numeric pain scale 13. The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials? (Arrange from first on top to last on the bottom) Verify the drug and dose with the label on the vial Inject the volume of air to be aspirated from each vial Aspirate the desired volume from vial A Aspirate the desired volume from vial B 14. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? • Express feelings of sadness and loneliness • Neglects personal hygiene and has no appetite • Lacks interest in the activity of the family and friends • Begin to show signs of improvement in affect 15. The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply) Close car windows and use air conditioner Avoid sudden changes in temperature Keep away from pets with long hair Stay indoors when grass is being cut 16. After an elderly fe