HESI EXIT V4 Questions and Answers

The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A. Make certain the child is maintained in correct body alignment. B. Be sure the traction weights touch the end of the bed. C. Adjust the head and foot of the bed for the child's comfort D. Release the traction for 15-20 minutes every 6 hours PRN. - A. Make certain the child is maintained in correct body alignment. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider? A. Height and weight percentiles vary widely B. Growth pattern appears to have slowed C. Recumbent and standing height changes are uneven D. Short term weight changes are uneven - A. Height and weight percentiles vary widely The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? A. Teach the parents how to perform cardiopulmonary resuscitation B. Recommend that the parents give in when he holds his breath to prevent anoxia C. Advise the parents to ignore breath holding because breathing will begin as a reflex D. Instruct the parents on how to reason with the child about possible harmful effects - C. Advise the parents to ignore the breath holding because breathing will begin as a reflex The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? A. "My pain is deep in my chest behind my sternum" B. "When I sit up the pain gets worse" C. "As I take a deep breath the pain gets worse" D. "The pain is right here in my stomach area" - A. "My pain is deep in my chest behind my sternum" The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory? A. "Name the year." What season is this?" (pause for answer after each question) B. "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number." C. "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." D. "What is this on my wrist? (point to your watch) Then ask, "What is the purpose of it?" - C. "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." In planning care for a 6-month old infant, what must the nurse provide to assist in the development of trust? A. Food B. Warmth C. Security D. Comfort - C. Security A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A. "I cannot give the medication as it is written. I have no idea of what you mean." B. "Would you please clarify what you have written so I am sure I am reading it correctly?" C. "I am having difficulty reading your handwriting. It would save me time if you would be more careful." D. "Please print in the future so I do not have to spend extra time attempting to read your writing." - B. "Would you please clarify what you have written so I am sure I am reading it correctly?" What is the most important consideration when teaching parents how to reduce the risk in the home? A. Age and knowledge level of the parents B. Proximity to emergency services C. Number of children in the home D. Age of children in the home - D. Age of children in the home A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should A. Administer a placebo B. Encourage increased fluid intake C. Administer the prescribed analgesia D. Recommend relaxation exercises for pain control - C. Administer the prescribed analgeisa While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? A. Respiratory rate of 30 B. Lethargy for the past hour C. Apical pulse of 54 D. Coughing up copious secretions - C. Respiratory rate of 30 (or 42) A client is admitted with low T3 and T4 levels an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? A. Lethargy B. Heat intolerance C. Diarrhea D. Skin eruptions - A. Lethargy