HESI 799 RN EXIT EXAM (709-810)-102 QUESTIONS FULLY SOLVED & UPDATED 2024

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement? a- Obtain the results for STAT serum cardiac biomarkers b- Asses for contraindications for thrombolytic therapy c- Measure ST-segment height and waveform changes. d- Transfer for percutaneous coronary intervention (PCI) b. Asses for contraindications for thrombolytic therapy. Rationale: ST segment elevation myocardial infarction (STEMI) usually occurs with complete occlusion of an epicardial coronary artery which requires early reperfusion therapy. Screening the client for fibrinolytic therapy (B) is most important to determine PCI option for rapid reperfusion. If the client is not a candidate for fibrinolytic therapy, then transfer to a PCI unit or facility is indicated. Reperfusion therapy should be delayed in STEMI (A). (C) is of significant concern in ECG interpretation with ST-segment depression, not STEMI An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? a. 1000, 1600, 2200, 0400 1000, 1600, 2200, 0400 Brainpower Read More Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:00 Full screen A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse? a. Leakage around catheter insertion site Leakage around catheter insertion site A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply.) A. Headache and tremors. B. Postural hypotension. C. Pallor and diaphoresis. D. Skin hyperpigmentation. E. Irregular heart beat. A. Headache and tremors. B. Postural hypotension. C. Pallor and diaphoresis. E. Irregular heart beat. Rationale: (A, B, C, and E) are correct. Addison's crisis results from an acute lack of adrenal cortical hormones. Headache and tremors (A), as well as pallor and diaphoresis (C) may indicate significant hypoglycemia. Hypotension (B) with pale, diaphoretic skin (C) are indicative of progressing signs of life-threatening shock that also require immediate nursing intervention. An irregular heart rate (E) may be the result of hyperkalemia and also requires immediate intervention. (D) is consistent with chronic secondary adrenal insufficiency and does not require immediate nursing intervention. A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care? a. Evaluate daily blood clotting factors. Evaluate daily blood clotting factors. The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first? a. Evaluate the oxygen saturation Evaluate the oxygen saturation During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide? a. Dialysis would need to be resumed if chronic rejection becomes a reality Dialysis would need to be resumed if chronic rejection becomes a reality The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first? a. Place the side rails in an up position Place the side rails in an up position A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication? a. Chest pain and dysrhythmia Chest pain and dysrhythmia A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make? a. Contact the healthcare provider immediately to report the laboratory value regardless of the advice Contact the healthcare provider immediately to report the laboratory value regardless of the advice We have an expert-written solution to this problem! A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste "bitter". He complains that he simply has no appetite. What action should the nurse implement? a. Suggest the use of alternative sources of protein such as dairy products and nuts Suggest the use of alternative sources of protein such as dairy products and nuts Which actions should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.) Correct order: 1. Place stethoscope in suprasternal area to auscultate from bronchial sounds 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds 1. Place stethoscope in suprasternal area to auscultate from bronchial sounds 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds We have an expert-written solution to this problem! A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication? a. Blood pressure 90/76 mm Hg Blood pressure 90/76 mm Hg The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? a. Recommend weigh bearing physical activity Recommend weigh bearing physical activity Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately? a. Upper airway stridor Upper airway stridor During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage A. natural whole almonds B. lightly salted potatoe chips C. Cheddar cheese cubes D. Canned fruits in heavy syrup E. plain, air-popped popcorn A. Natural whole almonds E. Plain, air-popped popcorn A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? a. Hydrocortisone Rationale: Hydrocortisone tablets work as a hormone replacement for a natural hormone called cortisol. You may take hydrocortisone tablets if your body does not make enough cortisol – for example if you have Addison's disease or if you've had your adrenal glands taken out. Hydrocortisone An adolescent, whose mother recently died, comes to the school nurse complaining of a headache. Which statement made by the students should warrant further explanation by the nurse? A. "I've had dreams about Mon since she died." B. "I've been very sad and cry a lot at night." C. "I miss Mom and would like to go see her'". D. " it's hard to concentrate on my homework" C. "I miss Mom and would like to go see her'". When washing soiled hands, the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top last action on bottom.) 1. Rub hands palm to palm. 2. Interlace the fingers, 3. Dry hands with paper towel. 4. Turn off the water faucet. 1. Rub hands palm to palm. 2. Interlace the fingers, 3. Dry hands with paper towel. 4. Turn off the water faucet. A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse? a. Give IV dose of adenosine rapidly over 1-2 seconds. Give IV dose of adenosine rapidly over 1-2 seconds. 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. Monitor for secondary infections. The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? a. Plastic tubing located at the chest insertion site Plastic tubing located at the chest insertion site We have an expert-written solution to this problem! While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? a. Discontinue the painful IV after a new IV is inserted Discontinue the painful IV after a new IV is inserted We have an expert-written solution to this problem! An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure should the nurse prepare for first? a. Insertion of a left- sided chest tube. Insertion of a left- sided chest tube. During a staff meeting, a nurse verbally attacks the nurse manager conducting the meeting, stating, "you always let your favorites have holidays off give then easier assignments. You are unfair and prejudiced" how should the nurse-manager respond? a. Give me specific examples to support your statements. Give me specific examples to support your statements. We have an expert-written solution to this problem! A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement? a. Administer PRN dose of albuterol Administer PRN dose of albuterol A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? a. Furosemide Rationale: Furosemide is given to help treat fluid retention (edema) and swelling that is caused by congestive heart failure, liver disease, kidney disease, or other medical conditions. It works by acting on the kidneys to increase the flow of urine. Furosemide The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply) a. Ease the client to the floor b. Loosen restrictive clothing c. Note the duration of the seizure a. Ease the client to the floor b. Loosen restrictive clothing c. Note the duration of the seizure When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? a. Leave the room and close the door quietly Leave the room and close the door quietly We have an expert-written solution to this problem! A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? a. Vomiting Vomiting The nurse suspect a patient may be hemorrhaging internally. Which findings of an orthostatic test may indicate signs to the nurse of a major bleed? a. A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20. A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20. An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the nurse, "How does this help my GERD?" What is the best response by the nurse? a. Antacids will neutralize the acid in your stomach Antacids will neutralize the acid in your stomach A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff. Which assessments finding is most important for the nurse to identify in the first 24 hours? a. Agitation and threatens to harm the staff Agitation and threats to harms staff We have an expert-written solution to this problem! A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? a. Avoid exposure to large crowds Avoid exposure to large crowds A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention? a. Maintain contact transmission precautions Maintain contact transmission precautions