HESI Comprehensive B Comprehensive Exam A exit v 2 Latest Update 2023

HESI Comprehensive B Comprehensive Exam A exit v 2 Latest Update 2023 The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A. Suctions oral secretions from mouth B. Positions head of bed flat when changing sheets C. Takes temperature using the axillary method D. Keeps head of bed elevated at 30 degrees B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration The others are all acceptable tasks performed by the UAP (A, C, and D). (B). When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse? A.Sodium level, 137 mEq/L B.Potassium level, 5.5 mEq/L C.Blood urea nitrogen (BUN) level, 18 mg/dL D.Calcium level, 10 mEq/L B Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D). Which vaccination should the nurse administer to a newborn? A A.Hepatitis B Rationale: B.Human papilloma virus (HPV) The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is not C.Varicella recommended until adolescence (B). Varicella immunization begins at 12 months (C). Meningococcal vaccine is D.Meningococcal vaccine administered beginning at 2 years (D). The nurse is caring for a client on the medical unit. Which task can be B delegated to unlicensed assistive personnel (UAP)? Rationale: A.Assess the need to change a central line dressing. Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform B.Obtain a fingerstick blood glucose level. (B). (A, C, and D) are skills that cannot be delegated to UAP. C.Answer a family member's questions about the client's plan of care. D.Teach the client side effects to report related to the current medication regimen. The nurse is caring for a client with an ischemic stroke who has a B,C,E prescription for tissue plasminogen activator (t-PA) IV. Which action(s) Rationale: should the nurse expect to implement? (Select all that apply.) Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This includes close A.Administer aspirin with tissue plasminogen activator (t-PA). monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, B.Complete the National Institute of Health Stroke Scale (NIHSS). the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the risk for C.Assess the client for signs of bleeding during and after the infusion. bleeding (A). The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial D.Start t-PA within 6 hours after the onset of stroke symptoms. infarction and within 4.5 hours of symptoms is concurrent for a stroke (D). E.Initiate multidisciplinary consult for potential rehabilitation. When caring for a client in labor, which finding is most important to B report to the primary health care provider? Rationale: A.Maternal heart rate, 90 beats/min. A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average FHR at term is 140 B.Fetal heart rate, 100 beats/min beats/min and the normal range is 110 to beats/min 160. The others (A, C, and D) are normal findings for a woman C.Maternal blood pressure, 140/86 mm Hg in labor. D.Maternal temperature, 100.0° F The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action C Rationale: