HESI RN EXIT Exam Questions and Answers_ A+ Graded 100% Pass The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Brad

HESI RN EXIT Exam Questions and Answers_ A+ Graded 100% Pass The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia - CORRECT ANSWER-C) Distended neck veins A pt presses the call bell and requests pain medication for a severe headache. To assess the quality of the pt. Pain, which approach should the nurse use? - CORRECT ANSWER-Ask the patient to describe the pain The nurse is wearing personal protective equipment while caring for a pt. When exiting the room, which PPE should be removed first? - CORRECT ANSWER-Gloves An older pt is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication? - CORRECT ANSWER-Increasing confusion of the pt. A pt tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The pt states that it still is taking hours to fall asleep at night. Which action should the nurse implement? - CORRECT ANSWER-Ask the pt for a description of the exercise schedule that is being followed 2 days prior to discharge from the rehab facility, the nurse is teaching a pt who is recovering from Guillain-Barre syndrome about home. Which actions should the nurse include when providing discharge teaching to the pt and spouse? SATA - CORRECT ANSWER--review safe transfer strategies -develop a nutritional plan -help identify community support The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? - CORRECT ANSWER-pt who develop disease complications promptly received rehabilitation The nurse has received funding to design a health promotion project for African American women who are at risk for developing breast cancer. Which resource is most important in designing this program? - CORRECT ANSWER-participation of community leaders in planning the program A pt with multiple injuries is being treated in the burn trauma unit just hours after the injuries occurred. The healthcare provider instructs the nurse to avoid auto contamination when performing dressing changes. Which intervention is most important for the nurse to implement? - CORRECT ANSWER-use gown, mask, and gloves with dressing changes A pt is recovering in the critical care unit following a cardiac cath. IV nitro and heparin are infusing. The pt is sedated but responds to instructions. After changing positions, the pt complains of pain at the right groin insertion site. What action should the nurse implement? - CORRECT ANSWER-Stimulate the pt to take deep breaths Prior to obtaining a trapeze bar for a pt with limited mobility, which pt assessment is most important for the nurse to obtain? - CORRECT ANSWER-upper body muscle strength While the nurse is assessing an older pt fall risk, the pt reports living at home alone and never falling. Which action should the nurse take? - CORRECT ANSWER-Continue to obtain pt data needed to complete the fall risk survey The nurse is feeding an older adult who was admitted with aspiration pneumonia. The pt is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? - CORRECT ANSWER-Teach coughing and deep breathing exercises The nurse is teaching the pt about home care after surgery for an ileal conduit placement. When reviewing the information, which statement should the nurse recognize as needing additional education? - CORRECT ANSWER-Empty the pouch when it is half full. A 12 week gestation is admitted to the antepartum unit with a dx of hyperemesis gravidarum. Which action is most important for the nurse to implement? - CORRECT ANSWER-initiate prescribed IV fluids A pt with dyspnea is being admitted to the medical unit. To best prepare for the pt arrival, the nurse should ensure that the pt bed is in which position? - CORRECT ANSWER-Picture with the bed sitting up A pt who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. In preparing the pt for the procedure, which intervention has the highest priority? - CORRECT ANSWER-Instruct pt to write down questions While caring for a pt post operative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the provider, the nurse should review which of the pt lab values? - CORRECT ANSWER-culture for sensitive organisms A pt with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO every 12hrs. When the client requests an afternoon snack, which dietary choice should the nurse provide? - CORRECT ANSWER-Cinnamon apple sauce An older male reporting abd pain is admitted from a facility. It has been 7 days since his last BM and his abd is distended, and he just vomited 150ml of dark brown emesis. In what order should the nurse implement these interventions? - CORRECT ANSWER-Send emesis to lab Elevate HOB complete focused assessment offers PRN pain meds A patient who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the med. Which side effect should the nurse report to the healthcare provider? - CORRECT ANSWER-Somnambulism A pt is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow up by the nurse? - CORRECT ANSWER-take metformin for type 2 diabetes The nurse should withhold which medication if the client's serum potassium level is 6.2 mEq/? - CORRECT ANSWER-Spironolactone A nurse receives a report on a pt who is four hours post-total abdominal hysterectomy. The previous nurse reports that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first? - CORRECT ANSWER-Assess for weakness or dizziness A pt who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the pt, in which sequence should the nurse complete these actions? - CORRECT ANSWER--Observe breathing patterns -assess blood pressure -measure body temp -palpate for pedal edema The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the admission assessment is relevant to the nurse's plan for taking the blood pressure reading? SATA - CORRECT ANSWER-Blurred Vision Flat Affect frequent syncope After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication? - CORRECT ANSWER-Ask the pt about gastrointestinal pain A pt is receiving enoxaparin 30 mg subcutaneously twice a day. In assessing for adverse effects of the medication, which serum laboratory value most important for the nurse to monitor - CORRECT ANSWER-platelet count A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teach the parents to report which sign of overdose? - CORRECT ANSWER-Bradycardia The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel working on a rehab unit. The UAP asks the nurse how to safely move a physically disabled pt from the... wheelchair to the bed. Which action should the nurse recommend? - CORRECT ANSWER-Place the pt locked wheelchair on the pt strong side next to the bed The nurse has completed the diet teaching of a client who is being discharged following tx of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the pt indicates that the teaching was effective? - CORRECT ANSWER-A tuna fish sandwich with chips and ice cream When conducting diet teaching for a pt who was dx with a myocardial infarction, which snack foods should the nurse encourage the pt to eat? SATA - CORRECT ANSWER-Fresh Turkey slices and berries chick bouillon soup and toast raw unsalted almonds and apples A pt taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first? - CORRECT ANSWER-Observe the appearance of the stool A pt is dx with Meniere's disease. Which problem should the nurse identify as most important in the plan of care? - CORRECT ANSWER-Risk for injury related to vertigo A new nurse preparing to irrigate an IV catheter is attaching a 24 gauge needle. Which action should the charge nurse implement? - CORRECT ANSWER-Suggest the nurse use 20g needle A nurse working on an Endocrine Unit should see which client first? - CORRECT ANSWER-A pt taking corticosteroids who has become disoriented in the last two hours. After an older pt receives tx for drug toxicity the healthcare provider prescribes a 24 hr creatinine clearance, the nurse notes that the pt serum creatinine is 0.3mg. Which action should the nurse implement? - CORRECT ANSWER-Notify the healthcare provider of the results An older adult pt with Systemic inflammatory syndrome (SIRS) has a temp of 101.8, HR of 110, and RR of 24 breaths/min. Which additional finding is most important to report to the healthcare provider? - CORRECT ANSWER-Serum Creatinine of 2mg/dl