HESI NCLEX PN Exam Answer Key for 2023 Graded A

50) A client is brought to the ED by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. obtain a court order for the surgical procedure 2. ask the EMS team to sign the informed consent 3. transport the victim to the operating room for surgery 4. call the police to identify the client and notify the family 51) A nurse has just assisted a client back to bed after a fall. The nurse and primary healthcare provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next? 1. reassess the client 2. conduct a staff meeting to describe the fall 3. contact the nursing supervisor to update info regarding the fall 4. document in the nurse's notes that an occurrence report was completed 52) A nurse arrives at work and is told to float to the ICU for the day because they're understaffed and need additional nurses to care for clients. The nurse has never worked in the ICU. The nurse should take which best action? 1. refuse to float to the ICU because of lack of unit orientation 2. clarify the ICU client assignment with the team leader to ensure it's a safe assignment 3. ask the nursing supervisor to review the hospital policy on floating 4. submit a written protest to nursing administration, and then call the hospital lawyer 53) As a nurse is providing care, the client suddenly experiences a tonic-clonic seizure. The nurse would immediately: A) Call the physician B) Turn the client to the side C) Restrain the client's limbs D) Insert an airway in the client's mouth 54) A nurse is providing care to a client with a closed chest tube drainage system. When the nurse assists the client in turning onto his side, the chest tube is accidentally dislodged from the insertion site. The nurse must immediately: A) Contact the physician B) Reinsert the chest tube C) Turn the client onto his back D) Apply pressure over the chest tube insertion site 55) A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes an audible wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. After immediately disconnecting the suction source from the catheter, which intervention does the nurse implement next? A) Calling a code B) Administering an inhaled bronchodilator C) Connecting oxygen to the suction catheter D) Encouraging the client to take deep breaths 56) A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? 1. Many choose not to have health insurance. 2. They believe that health is a gift from God. 3. The authority of women is equal to that of men. 4. They remain secluded and avoid helping others. 5. They use both traditional and alternative health care, such as healers, herbs, and massage. 6. Funerals are conducted in the home without other an eulogy, flower decorations, or any play. Caskets are plain and simple, without adornment. 57) A client is receiving an enteral feeding that delivers 1.5 calories/mL. The feeding is infusing at 30 mL/hr via a feeding pump. Which is the maximal amount of calories the client should receive in an 8- hour period if the tube feeding is not interrupted? 58) A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement? 1) "I would try anything that I could if I had cancer." 2) "You need to ask your health care provider about it." 3) "No, because it will interact with the chemotherapy." 4) "Let's talk more about the different forms of complementary therapies." 4; Although the HCP should approve the use of a complementary therapy, it is important for the nurse to explore the complementary therapies first with the client, which would eliminate option 2. Options 1 and 3 are inappropriate. 59) The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal? 1) Unwrapping the eating utensils for the client 2) Replacing the plastic utensils with metal utensils 3) Carefully transferring food from the paper plates to glass plates 4) Allowing the client to unwrap the utensils and prepare his own meal for eating 4; Kosher meals arrive on paper plates and with plastic utensils sealed. Health care providers should not unwrap the utensils of transfer the food to another serving dish. Although the nurse may want to be helpful in assisting the client with the meal, the only appropriate option is option 4. 60) The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions in regard to avoiding the use of herbal medications? 1) A 60-year-old male client with rhinitis 2) A 24-year-old male client with a lower back injury 3) A 10-year-old female with a urinary tract infection 4) A 45-year-old female client with a history of migraine headaches 3; Children should not be given herbal therapies, especially in the home and without professional supervision.