HESI Exit Exam 7 Graded A+ 2023

1. A client returns to the postoperative unit following an open reduction and internal fixation of a hip fix. the PN applies the prescribed sequential compression device (SCD) to both lower extremities. WHAT ACTION IS IMPORTANT WHEN TURNING THE CLIENT TO A LATERAL POSITION? Observe the SCDs continue to inflate and deflate when the client is turned. 2. While the PN assists a postoperative client with an incentive spirometer, the client experiences wound evisceration. WHAT ACTION SHOULD THE PN TAKE? Call for immediate assistance. 3. The PN finds a postoperative client lying in bed with a unsecured surgical dressing. After reinforcing the dressing, WHAT FOLLOW UP ASSESSMENT IS MOST IMPORTANT FOR THE PN TO IMPLEMENT? Vital signs measurement. 4. The scope of practice for the PN includes which CLIENT ASSESSMENT? An agitated client with b/l wrist restraints. 5. Which intervention is within the scope of practice for a PN? Demonstrating deep breathing and coughing to a postoperative client. 6. Which nursing activity is within the scope of practice for a PN? Observe client rotate the SQ site for an insulin pump. 7. The nurse is assessing care for residents on 12-bed unit in an extended care facility. The staff consists of 1 unlicensed UAP and 1 certified medication aide. WHICH TASK SHOULD THE NURSE PERFORM? Change a hydrocolloid dressing for a client with a stage II pressure ulcer. 8. A PN who works on a 16-bed of an extended care facility with an additional P and a UAP is told that the other PN will not be in because of illness. The facility manager agrees to obtain another UAP for the day. WHICH ACTION SHOULD THE PN TAKE? Prioritize assessment of safety issues in addition to administration of daily medication. 9. In working with UAP to provide care for an immobile client, WHICH TASK SHOULD THE NURSE PERFORM, RATHER THAN THE UAP? Cover a skin tear with a transparent dressing. 10. A nurse sees a college taking drugs from the hospital unit. WHAT ACTION SHOULD THE NURSE TAKE? Report the incident to the person in charge of the unit or nursing supervisor. 11. The PN finds a client who is assigned to another nurse bleeding from an IV site and the IV tubing and fluid are on the floor. The PN immediately applies a dressing to stop the bleeding. WHAT ACTION SHOULD THE PN TAKE NEXT? Enter computer documentation of the findings and the application of a dressing. 12. During report, the PN is told that a client has 4+ pitting edema of both feet and ankles. The PN observes the client's lower extremities and finds 2+ pitting edema b/l. WHAT ACTION SHOULD THE PN TAKE? Enter computer documentation of the finding. 13. The UAP working in a small community hospital obtains 0800 V/S measurements of clients on the unit. In reviewing these vital signs, WHICH MEASUREMENT WARRANTS IMMEDIATE INTERVENTION BY THE NURSE? A one-month-old infant with a HR of 80 bpm. 14. The nurse is assigned to care for four children. WHICH CHILD SHOULD BE ASSESSED FIRST? 18-month-old who has cystic fibrosis and is wheezing. 15. On a short-staffed unit of a long-term are facility, it is most important that the nurse assign the UAP to complete this morning care for the resident with which problem first? Frequent episodes of fecal incontinence. 16. Which client should the nurse assess first? A client who is ambulating with partial weight-bearing after a total hip replacement. 17. After report, the nurse receives the laboratory values for 4 clients. Which client requires the nurse's immediate intervention? The client who is: Trembling and has a glucose level of a 50 mg/dL. 18. The PN who is working as the charge nurse at an extended care facility is making assignments for the UAP working a 12-hour shift. WHICH RESOURCE IS MOST IMPORTANT IN GUIDING THE PN's assignments of the UAPs? The state's Nurse Practice Act regarding delegation to unlicensed personnel. 19. In caring for a client following a BKA, WHICH TASK IS BEST FOR THE NURSE TO DELEGATE TO THE UAP who is assisting with the care of this client? Empty and measure the drainage in the suction drainage device. 20. Which client should the nurse assign to a UAP? A client who has a regular HR after a pacemaker replacement and now needs to ambulate. 21. Which task could the nurse safely delegate to the UAP? Oral feeding of a two-year-old child after application of a hip spica cast. 22. The nurse assigns a UAP to feed a client who is at risk for aspiration. To ensure that the task is safely delegated, WHAT ACTION SHOULD THE NURSE IMPLEMENT? Observe the UAP's ability to implement precautions during feeding. 23. The nurse is in charge of a nursing unit in a long-term care facility. WHICH TASK IS BEST FOR THE NURSE ASSIGN TO A UAP who is helping with the care of SEVERAL clients? Cleanse the perineal area of client with urinary incontinence. 24. After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. WHAT ACTIVITY IS BEST FOR THE NURSE TO ASSIGN TO THE UAP? Provide perianal care and collect clean linens for the dressing change. 25. A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the nurse identifies that a UAP has omitted a vital component of the protocol. AFTER IMPLEMENTING THE MISSING COMPONENT, WHAT ACTION SHOULD THE PN TAKE? Supervise the UAP after reviewing the protocol.