HESI PRACTICE EXAM 1 WITH COMPLETE SOLUTION 2023

HESI PRACTICE EXAM 1 Administer Prescribed stool softener - The nurse is planning care for the a client who has fourth degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priority? Liver - The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area. Amenorrhea - A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report? Ask for a description of what happened during the night - A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make? Report any drainage observed around the GT insertion site - The nurse is providing instructions to the unlicensed assistive personnel (UAP) preparing to instruction is most important for the nurse to emphasize? Pinna - The nurse can also refer to the external ear as what other known name... . Re-teach the client about the action of the eye drops to decrease pressure in the eye - The nurse is reviewing instructions for the use of pilocarpine eye drops with a client who has Glaucoma. The client states, "I should have these drops to anesthetize my eye if I experience pain" What action should the nurse implement? Close the rectal wall the prostate gland sits behind the symphysis pubis extending around the beginning of the urethra - A client asks the nurse to explain the location of the prostate gland. What is the best response? Respiratory obstruction - During immediate postoperative period, which condition has the highest priority when planning Nursing care? Reposition the oximeter clip - During vital sign assessment of a client, the nurse counts the left radial pulse at 88, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 with an oxygen saturation of 95%. What is the best initial action by the nurse? Serum potassium 6 mEq/L, serum sodium 126 mEq/L, and serum chloride 115 mEq/L - The nurse is caring for an elderly client who has suddenly become confused after 2 days of vomiting and diarrhea. What laboratory result should the nurse report first to the RN? A. A young female client who reports that she is afraid of her roommate who is psychotic B. An older client who is asking for a priest to offer Last Rites C. A female client who is anxious about being discharged because she has no assistance at home - Which client should the nurse assess first? Autonomy vs. Shame and doubt. - A hospitalized toddler who is recovering from a sickle cell crisis holds a toy and say's "mine". According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage? Provide a Yankauer tip for oral suction - While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement? Wash any paste from the client's hair and scalp - Which action should the nurse implement in caring for a client following an electroencephalogram (EEG)? Encourage the client to eat foods high in protein - The nurse is caring for a 75- year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus? Osmosis - What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space? At the level of the heart - The nurse is taking blood pressure of a client admitted with a possible myocardial infarction. When taking the client's BP at the brachial artery, the nurse should place the client's arm in which position? Heart rate Stroke volume Peripheral resistance - What are the final parameters that produce blood pressure? (select all that apply) Mood - A client begins an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant? Give the rubella vaccine subcutaneously - Based on the documentation in the medical record, which action should the nurse implement next? Encourage mobilization and ambulation - A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the nurse implement to prevent complications associated with Pneumonia? 400 ANS 1 gram x 1000 divided by 2.5ml=400mg - The practical nurse is preparing to administer a prescription for cefazolin (kefzol) 600 mg IM every 6 hours. The available vial is labeled, "Cefazolin (Kefzol) 1 gram and the instructions for reconstitution, "For IM use add 2.5ml sterile water for injection. Total volume after reconstruction = 2.5 ml. "when reconstituted, how many milligrams are in each mil of solutions (Enter numeric value only) Observe a client rotate the subcutaneous site for an insulin pump - Which nursing activity is within the scope of practice for the practical nurse? Provide perineal care and collect clean linens for the dressing change - 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 unlicensed assistive personnel? Intravenous, Sublingual, Intramuscular, Subcutaneous, Oral. (ISISO) - The nurse is planning to evaluate the effectiveness of several drugs administered by different routes. Arrange the routes of administration in the order from fastest to slowest rate of absorption. Express sorrow for the client's grief and offer to sit with her - A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-house post dilation and curettage (D&C) the nurse assess the vital signs and vaginal bleeding. The client begins to cry softly. How should the nurse intervene? Enhance symptom management to improve end of life quality - A terminally ill male client and his family are requesting hospice care after discharge from the hospital and ask the nurse to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care? Encourage the wife to continue shaving her husband - The nurse observes a wife shaving her husband's beard with a safety razor by holding the skin taut and shaving in the direction of the hair growth . What action should the nurse take? Posterior tibial artery, Dorsalis pedis artery - To assess pedal pulse what arterial sites should the nurse palpate? (select all that apply) Smokes one pack of cigarettes daily - The nurse is admitting a client who is diagnosed with Angina Pectoris. Which precipitating factor in this client's history is likely to be related to the anginal pain? Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon. - The nurse is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catheterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's PO intake is 600 mL, and fifteen minutes ago, the client voided 90 mL. What action should the nurse take?