HESI RN Exit Exam 2023

The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)? A. Tachycardia and tachypnea B. Sluggish and unequal pupillary responses C. Increased head circumference and bulging fontanels D. Blood pressure fluctuations and syncope Answer- B. Sluggish and unequal pupillary responses A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse? A. Abdominal pain decreases when lying supine B. Pain lasts an hour and leaves the abdomen tender C. Right upper quadrant pain refers to right scapula D. Drinks alcohol until intoxicated at least twice weekly. Answer- A. Abdominal pain decreases when lying supine A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A. Instructions about how much fluid the child should drink daily. B. Signs of addiction to opioid pain medications C. Information about non-pharmaceutical pain relief measures D. Referral for social services for the child and family Answer- A. Instructions about how much fluid the child should drink daily To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the location on the image with a red dot). Answer- I placed the red dot on the base of the neck on the right side After receiving report on an inpatient acute care unit, which client should the nurse assess first? A. The client with an obstruction of the large intestine who is experiencing abdominal distention B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity Answer- D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis Answer- D. Respiratory alkalosis A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position? A. Supine B. supine; feet elevated higher than head C. supine; head elevated higher than feet D. Fowlers Answer- D.Fowlers The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? (Select all the apply) A. Frequent syncope B. Occasional nocturia C. Flat affect D. Blurred vision E. Frequent drooling Answer- A. Frequent syncope C. Flat affect D. Blurred vision