HESI RN EXIT EXAM 800 QUESTIONS AND ANSWERS WITH RATIONALE

HESI RN EXIT EXAM 800 QUESTIONS AND ANSWERS WITH RATIONALE Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? a. Remind the client that it is also important to switch to decaffeinated coffee and tea. b. Suggest that the client also plan to eat frequent small meals to reduce discomfort c. Review with the client the need to avoid foods that are rich in milk and cream. d. Reinforce this teaching by asking the client to list a dairy food that he might select. Review with the client the need to avoid foods that are rich in milk and cream Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be avoided. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? a. Blindness secondary to cataracts b. Acute kidney injury due to glomerular damage c. Stroke secondary to hemorrhage d. Heart block due to myocardial damage Stroke secondary to hemorrhage Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled hypertension. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? a. Ensure that the UAP has placed the pillows effectively to protect the client. b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. c. Assume responsibility for placing the pillows while the UAP completes another task. d. Ask the UAP to use some of the pillows to prop the client in a side lying position. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest because the use of pillows could result in suffocation and would need to be removed at the onset of the seizure. The nurse can delegate paddling the side rails to the UAP An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up a. Describes life without purpose b. Complains of nausea and loss of appetite c. States is often fatigued and drowsy d. Exhibits an increase in sweating. Describes life without purpose Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is known to increase the risk of suicidal thinking in adolescents and young adults with major depressive disorder. B, C and D are side effects A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan a. Further evaluation involving surgery may be needed b. A pelvic exam is also needed before cancer is ruled out c. Pap smear evaluation should be continued every six month d. One additional negative pap smear in six months is needed. Further evaluation involving surgery may be needed Rationale: An abdominal mass in a client with a family history for ovarian cancer should be evaluated carefully A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? a. Explain how to use communication tools. b. Teach tracheal suctioning techniques c. Encourage self-care and independence. d. Demonstrate how to clean tracheostomy site. Teach tracheal suctioning techniques Rationale: Suctioning helps to clear secretions and maintain an open airway, which is critical. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement a. Encourage the client to take deep breaths b. Remove the mask to deflate the bag c. Increase the liter flow of oxygen d. Document the assessment data Document the assessment data Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory rate is within normal limits.