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PN HESI EXAM WITH COMPLETE SOLUTION RATED A

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A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse?ANSWERS-A multiparous client who is dilated 5 cm and 50% effaced A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client?ANSWERS-Oral hygiene should be performed before the medication. A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client?ANSWERS-Sitting upright and forward with both arms supported on an over the bed table A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level?ANSWERS-The client's renal function has affected his potassium level. A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit?ANSWERS-Sending medical records to health care providers via the Internet Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP.ANSWERS-D The greatest risk associated with opioids such as morphine (D) is respiratory depression that causes an increase in Pco2, which increases ICP and masks the early signs of intracranial bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a client with increased ICP. The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other

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PN HESI EXAM WITH COMPLETE
SOLUTION RATED A+
Thyroidectomy patient with hoarse voiceANSWERS-Tell the charge nurse

What would you expect with a patient with hip replacement cast?ANSWERS-Decreased
HGB

If you are taking out the NG tube and your patient starts gagging, what would you do?
ANSWERS-Continue removing the NG tube

Something with a chamber of 15mLANSWERS-Choose the option to add 5mL to make
it 20mL

Nurse that has four patientsANSWERS-Pick the patient trying to get up (NOT liver
biopsy patient)

Know where the injection site is on the assANSWERS-Side top, where the dimple is

Patient wants to be DNRANSWERS-Tell the physician of the clients wishes

ParkinsonsANSWERS-Give levodopa

Patient comes in with TB, UTI, nurse looks at prescription and patient complains of
tinnitus, which drugs are you going to question?ANSWERS-Gentamicin

Foods that contain Vitamin K SATAANSWERS-Spinach & broccoli

Listening to the sounds of the lungsANSWERS-Give albuterol

Cleaning wound that has a drain, how does the PN cleanse that woundANSWERS-
Cleaning from the most drainage to the least

Husband of a patient is screaming, what stage is he experiencing?ANSWERS-Anger

Coumadin question that is increasingANSWERS-Just administer the next dose- 5mg.

Rationale: It says in the doctors order to give 2mg on the first day on 5 on the rest. Don't
get confused with Heparin's INR which will show that it's increasing because thats
normal

Incentive spirometer that shows they need more teachingANSWERS-Patient who is
blowing INTO it

,Catheter question about vulture sensitivityANSWERS-Use sterile syringe and get urine
from the port near the catheter

Thrombocytopenic patientANSWERS-Move all clutter out of the environment

Correct way to inject insulin (in order)ANSWERS-Sit the client up right, clean with swab,
pinch, release, and then inject

Newborn baby, why is there yellow drainage?ANSWERS-they get antibiotic eye drops
when they are first born

Thyroid patient receiving synthroid (Levothyroxine)ANSWERS-Monitor for palpitations

How do you know if your patient has jaundice?ANSWERS-Observe

Teenager being admitted to psycho unit, prior to leaving the room, what do you do?
ANSWERS-Ask her if she has suicidal tendencies

Malpractice question - which of these protect you?ANSWERS-Code of ethics

Within your scope of practiceANSWERS-Nurse Practice Acts

PCP tells UAP to cut diabetic toenailANSWERS-Inform the HCP of the diabetic foot
care policy

3 month old immunizationsANSWERS-Hep B

Ear question for toddlerANSWERS-Pull up and back for 4+

Cradle cap questionANSWERS-Use a soft bristle brush

Picture with nurse touching the outside of the sterile box, what would you tell her to do?
ANSWERS-Apply new sterile gloves

Schizophrenic patient is depressed sitting in their room. The next day they're diaphoretic
and pacing down the hallANSWERS-Put him near nursing station

Continuous feeding G tube and the bed is high and UAP is giving bed bathANSWERS-
Stay and watch

Lady with hella symptoms that isn't your patient and their IV comes out and she's
bleeding. What do you do after?ANSWERS-Document it yourself

Patient has a leg cast. What lab would be of most concern?ANSWERS-HBG 9

What is the most significant to report?ANSWERS-Coffee ground emesis

, Who among the clients should the nurse assess first?ANSWERS-Gravida 3 Para 3 who
delivered vaginally 2 hours ago

If you see your loch getting redder at home, what would you tell the patient to do ?
ANSWERS-Notify yourPCP and come back

Pillow question with abductionANSWERS-Pick picture with legs away from each other
not fully bent at knees

Where do you go to get bone marrowANSWERS-Iliac crest

What patient would you take action for first?ANSWERS-When nasal cannula is pressed
against her cheek

Pregnancy questionANSWERS-Termed 3
Abortion 3
Preterm 0
Living 2

Patient has 3 large, semi formed bowel movements while taking bisacodyl dulcolax.
What do you do?ANSWERS-Tell patient to with a glass of water

Kussumail respirations, what's another s/sANSWERS-Fruity breath

Client is receiving IV, what s/s would be most significant for the nurse to report?
ANSWERS-Pruritus and hives

Enema put three inches into rectum unclaimed and nothing happensANSWERS-Put the
bag of 6 inches higher

Mannitol- what would you monitorANSWERS-Input and output

Shingles/herpes- What is most concerning?ANSWERS-Weeping/crusting of blisters

Palliative care for dying man mottled legsANSWERS-Cover him with a blanket

Kidney question- What would be most concerning?ANSWERS-Decreased creatinine

In caring for a client with transient ischemic attacks, a priority nursing diagnosis would
beANSWERS-High risk for injury

After a cardiac catheterization, the nurse feels for the presence of pedal pulses. The
nurse needs to assess which arterial pulse site? SATAANSWERS-Posterior tibial artery
Dorsalis pedis artery

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