HESI EXIT V1 Test Bank | Exam Questions And Answers | Latest Updated (GRADED)

A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement? -- CORRECT ANSWER-Maintain both lower extremities elevated on pillows. A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care? -- CORRECT ANSWER-Teach family proper range of motion exercises. HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention? -- CORRECT ANSWER-Postmenopausal women need an intake of at least 1,500 mg of calcium daily. When evaluating a client's rectal bleeding, which findings should the nurse document? - - CORRECT ANSWER-Color characteristics of each stool. The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? -- CORRECT ANSWER-High pitched or fine crackles. Rhonchi High pitched wheeze Stridor An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement? -- CORRECT ANSWER-Explain the reason for using only non-narcotics. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) -- CORRECT ANSWER-Weigh the client and report any weight gain. Report any client complaint of pain or discomfort. Note and report the client's food and liquid intake during meals and snacks. Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care? -- CORRECT ANSWER-Medicate as needed for pain and anxiety. An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries? -- CORRECT ANSWER-Decrease prevalence of glaucoma in the population. HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? -- CORRECT ANSWER-Convey to the client that birth is imminent. To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement? -- CORRECT ANSWER-Remind the client to keep his appointments to have his cholesterol level checked. Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include? -- CORRECT ANSWER-Fall prevention measures. A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? -- CORRECT ANSWER-Infection Increase intracranial pressure Shock Head Injury. A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider? -- CORRECT ANSWER-New onset of purple skin lesions. 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? -- CORRECT ANSWER-Ensure that no dependent loops are present in the tubing. The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat? -- CORRECT ANSWER-Yogurt and/or buttermilk. Avocados and cheese Green leafy vegetables Fresh fruits HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? -- CORRECT ANSWER-An adult female who has been depress for the past several month and denies suicidal ideations. A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium. A young male with schizophrenia who said voices is telling him to kill his psychiatric. An elderly male who tell the staff and other client that he is superman and he can fly. Rationale: The RN should deal with the client with command hallucinations and these can be very dangerous if the client's acts on the commands, especially if the command is a homicidal in nature. Other client present low safety risk. A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug? -- CORRECT ANSWER-Maternal pulse rate of 162 beats per min In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis? -- CORRECT ANSWER-Anxiety related to fear of suffocation. A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care? -- CORRECT ANSWER-Provide daily care of tong insertion sites using saline and antibiotic ointment A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? -- CORRECT ANSWER-Determine the client's vital sign. A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider? -- CORRECT ANSWER-No wheezing upon auscultation of the chest. HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation? -- CORRECT ANSWER-During acute illness A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs? -- CORRECT ANSWER-Tell all their assigned clients to stay in their rooms. The nurse is auscultating is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) -- CORRECT ANSWER-Murmur s1 s2 pericardial friction rub s1 s2 s3 The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement? -- CORRECT ANSWER-Administer the medication via the oral route as prescribed A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer? -- CORRECT ANSWER-Simethicone (Mylicon) The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal? -- CORRECT ANSWERCase management and screening for clients with HIV. Regional relocation center for earthquake victims Vitamin supplements for high-risk pregnant women. Lead screening for children in low-income housing. Rational: Primary prevention activities focus on health promotions and disease preventions, so vitamin HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam for high-risk pregnant women provide adequate vitamin and mineral for fetal developmental. When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? -- CORRECT ANSWER-Arrange to transport the client to the hospital Instruct the client to keep a food journal, including portions size. Review the client's use of over the counter (OTC) medications. Reinforce the importance of keeping the feet elevated. Rationale: Sodium is used in several types of OTC medications. Including antacids, which the client may be using to treat his GERD. Further evaluation is need it to determine the need for hospitalization (A) A food journal (B) may help over, but dietary modifications are needed now since edema is present. (C) May relieve dependent edema, but not treat the underlying etiology. An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? -- CORRECT ANSWERMultiple organ dysfunction syndrome (MODS) Disseminated intravascular coagulation (DIC) Chronic obstructive disease. Acquired immunodeficiency syndrome (AIDS) Rational: MODS are a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has evidence of several organ systems that require intervention, such as blood pressure, hemoglobin, WBC, and respiratory rate. DIC may develop as a result of MODS. The other options are not correct. HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take? -- CORRECT ANSWERProvide the man and his mother with a copy of the Patient's Bill of Rights A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? -- CORRECT ANSWER-Administer naloxone (Narcan) per PNR protocol Initiate seizure precautions Obtain a serum drug screen Instruct the family about withdrawal symptoms. Rationale: Withdrawal of CNS depressants, such as Xanax, results in rebound overexcitation of the CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client. The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose? -- CORRECT ANSWER-Jaundice Nausea Fever Fatigue A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? -- CORRECT ANSWERExplain that it may take several weeks for the medication to be effective Confirm the desired effect of the medication has been achieved. Notify the health care provider than a change may be needed. Evaluate when and how the medication is being administered to the client. Rationale: Trazodone o Desyrel, an atypical antidepressant, is prescribed for client with AD to improve mood and sleep. A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? -- CORRECT ANSWER-Reduced level of pain HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam Full volume of pedal pulses Granulating tissue in foot ulcer Improved visual acuity A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment? -- CORRECT ANSWER-How many departments can use this equipment? Will the equipment require annual repair? Is the cost of the equipment reasonable? Can the equipment be updated each year? While receiving a male postoperative client's staples de nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledgement the client's anxiety, what action should the nurse implement? -- CORRECT ANSWER-Encourage the client to continue verbalize his anxiety Attempt to distract the client with general conversation Explain the procedure in detail while removing the staples Reassure the client that this is a simple nursing procedure. Rational: Distract is an effective strategy when a client experience anxiety during an uncomfortable procedure. (A & D) increase the client's anxiety. A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) -- CORRECT ANSWER-Collect multiple site screening culture for MRSA Call healthcare provider for a prescription for linezolid (Zyrovix) Place the client on contact transmission precautions Obtain sputum specimen for culture and sensitivity Continue to monitor for client sign of infection. Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infectant, is not indicated, unless the client has an active skin structure infection cause by MRSA or HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated9D) based on the client's history is a wound infection. A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device? -- CORRECT ANSWEREnsure the transparent dressing has no tears that might create vacuum leaks The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care? -- CORRECT ANSWERIncrease fluid intake to 3,000 ml/daily The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? -- CORRECT ANSWER-Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours. Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours is the correct procedure for collecting 24-hour urine specimen. Discarding even one voided specimen invalidate the test. The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification? -- CORRECT ANSWER-Decreases the amount of HCL secretion by the parietal cells in the stomach The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam of the drug's effectiveness? -- CORRECT ANSWER-Hemoglobin A1C (HbA1C) reading less than 7% The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? -- CORRECT ANSWER-Antibiotics Anticoagulants Antihypertensive Anticholinergics A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care? -- CORRECT ANSWER-Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90% Administer diuretics via secondary infusion in the morning only Evaluate heart rate for effectiveness of cardio tonic medications Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples Ensure Interrupted and frequent rest periods between procedures. Rationale: Pulse oximetry screening supports prescribed level of O2. HR provides an evaluative criterion for cardiac medications, which reduce heart rate, increase strength contractions (inotropic effects) and consequently affect systemic circulation and tissue oxygenation. Breast milk or basic formula provide 20 calories/ounce, so frequent feedings with high energy formula. D minimize fatigue is necessary. The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) -- CORRECT ANSWER-Start chest compressions with assisted manual ventilations Administer epinephrine 0.01 mg/kg intraosseous (IO) Apply pads and prepare for transthoracic pacing Review the possible underlying causes for bradycardia An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition? -- CORRECT ANSWER-Delirium Depression Dementia Psychotic episode Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply. -- CORRECT ANSWER-Prepare medication reversal agent Check oxygen saturation level Apply oxygen via nasal cannula Initiate bag- valve mask ventilation. Begin cardiopulmonary resuscitation Rationale: Sedation, given during the procedure may need to be reverse if the client does not easily wake up. Oxygen saturation level should be asses, and oxygen applied to support respiratory effort and oxygenation. The client is still breathing so the bag- valve mask ventilation and CPR are not necessary. The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement? -- CORRECT ANSWER-Give the child syringes or hospital mask to play it at home prior to hospitalization. Include the child in pay therapy with children who are hospitalized for similar surgery. Provide a family tour of the preoperative unit one week before the surgery is scheduled. Provide doll an equipment to re-enact feeling associated with painful procedures. Rationale: School age children gain satisfaction from exploring and manipulating their environment, thinking about objectives, situations and events, and making judgments based on what they reason. A tour of the unit allows the child to see the hospital environment and reinforce explanation and conceptual thinking. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm? -- CORRECT ANSWERAssess IV site frequently for signs of extravasation HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam 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? -- CORRECT ANSWERResume normal physical activity Drink electrolyte fluid replacement Give a dose of regular insulin per sliding scale Measure urinary output over 24 hours. Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client manifest early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should determine fingersticks glucose level and self-administer a dose of regular insulin per sliding scale. The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize? -- CORRECT ANSWER-Protect joint function Improve circulation Control tremors Increase weight bearing An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? -- CORRECT ANSWER-9 % 18 % 36 % 45 % Rational: according to the rule of nines, the anterior and posterior surfaces of one lower extremity is designated as 18 %of total body surface area (TBSA), so both extremities equals 36% TBSA, other options are incorrect. A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect? -- CORRECT ANSWER-Decrease in serum T4 levels HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam Increase in blood pressure Decrease in pulse rate Goiter no longer palpable An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation? -- CORRECT ANSWER-Consistently applies TED hose before getting dressed in the morning. Frequently elevated legs thorough the day. Inspect the leg frequently for any irritation or skin breakdown Completely stop cigarette/ cigar smoking. Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and improve arterial circulation to the extremity. A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem? -- CORRECT ANSWER-Establish trust with community leaders and respect cultural and family values The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? -- CORRECT ANSWER-The client's previous GCS score When the client's stroke symptoms started If the client is oriented to time The client's blood pressure and respiration rate Rationale: The normal GCS is 15, and it is most important for the nurse to determine if it abnormal score a sign of improvement or a deterioration in the client's condition The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? -- CORRECT ANSWER-Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation HESI EXIT With Questions And 100% Correct Answers Version/A GRADE/Real Exam Based on principles of asepsis, the nurse should consider which circumstance to be sterile? -- CORRECT ANSWER-One inch- border around the edge of the sterile field set up in the operating room A wrapped unopened, sterile 4x4 gauze placed on a damp table top. An open sterile Foley catheter kit set up on a table at the nurse waist level Sterile syringe is placed on sterile area as the nurse riches over the sterile field. Rationale: A sterile package at or above the waist level is considered sterile. The edge of sterile field is contaminated which include a 1-inch border (A). A sterile objects become contaminated by capillary action when sterile objects become in contact with a wet contaminated surface. An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? -- CORRECT ANSWER-Ask the UAP to take the blood pressure in the other arm Tell the UAP to use a different sphygmomanometer. Review the client's serum calcium level Administer PRN antianxiety medication. Rationale: Trousseau's sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.