HESI RN EXIT EXAM V2 2023(100% CORRECT & VERIFIED ANSWERS RATED A)(Next Gen Format)

1. The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 750 mg/dL. When assessing the client, what is the priority? a. Assess for signs of fluids volume deficit 2. A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull gnawing pain that is relieved when he eats. Which is the best response by the nurse? a. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer 3. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300mL of blood in the suction canister, the client’s heart rate is 155bpm, and his blood pressure is 78/48 mmHg. In addition to reporting the findings to the surgeon, which action should the nurse implement first? a. Increase the infusion rate of Lactated Ringer’s solution 4. A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose injection 250 mL. the nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number) a. 18 Rationale: 1st we calculate the weight; 220/2.2 = 100kg Then we calculate total dose in units; dose = 18 units x 100 = 1800 units/hr We use the reference to get the final answer 25,000units --- in 250mL 1800 units --- in X mL X = 1800 * 250/25,000 = 18 5. An adult male who fell 20 feet from her roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? a. Add sterile water to the suction control chamber 6. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband’s death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse? a. Explain that the client will start to lose consciousness and the body systems will slow down 7. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by the registered nurse (RN)? a. An 82-year-old client with Alzheimer’s disease and a newly fractured femur who has a Foley catheter and soft wrist restraints applied 8. The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled “750 mcg/2.4mL.” How many mL should the nurse administer? (if rounding is required, round to the nearest tenth) a. 0.2 9. In caring for a client with Cushing’s syndrome, which serum laboratory value is most important for the nurse to monitor? a. Glucose 10. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110bpm, and respiratory rate 36 bpm. The client manifested shortness of breath, bilateral 2+ edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? a. Begin supplement oxygen 11. When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention? (SATA) a. Complaint of increased pain and pressure b. Change in the quality of the peripheral pulse c. Loss of sensation to the left lower extremity 12. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? a. Skin tenting occurs when the client’s forearm is pinched 13. The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of the medication? a. Hypertension 14. After an in-service about electronic health record (HER) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? a. File a detailed incident report with the specific hiring facility 15. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective? a. Clients who incurred disease complications promptly received rehabilitation 16. While carrying for a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s laboratory values? a. Culture for sensitive organisms 17. A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs every 2 hours. Which finding should the nurse report immediately to the healthcare provider? a. Confusion and tremors 18. A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm. Which intervention is most important for the nurse to include in this client’s plan of care? a. Assess urine and stool for occult blood 19. When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? a. Sitting upright 20. A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? a. Evaluate swallow 21. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/min per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 bpm. Which action should the nurse implement first? a. Assess the delivery mechanism of the oxygen tank, tubing, and cannula 22. A client with a history of using illicit drugs intravenously is admitted with Kaposi’s sarcoma. Which intervention should the nurse include in this client’s admission plan of care? a. Monitor for secondary infections 23. An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client’s compliance with self-care? a. Have the client vocalize the instructions provided 24. An order woman with a history of atrial fibrillation fell at home and fractured her left hip. She is currently taking warfarin 5mg daily and has an international normalized ration (INR) value of 5.0. Upon admission, which prescription should the nurse expect to implement? a. Administer Vitamin K injection 25. A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 mL/hr. The client’s urine specific gravity is 1.035. What action should the nurse implement? a. Encourage popsicles and fluids of choice 26. Which instruction should the nurse provide to a client who is preparing to have a cystoscopy? a. Report any painful urination, blood in urine, or fever 27. What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? a. “When I get out of bed quickly, I feel a little dizzy” 28. An older adult male who is in his early 70’s is admitted to the emergency department because of COPD exacerbation. The client is struggling to breathe, and the healthcare team is preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than then client, asks the nurse to stop the procedure and provides the nurse a copy of the client’s living will. Which action should the nurse take? a. Notify the healthcare provider of the client’s wishes