Hesi exit 5 – (160) exam
Questions with complete
solutions.
Suicide precautions are initiated for a child admitted to the mental health unit
following an intentional narcotic overdose. After a visitor leaves, the nurse finds a
package of cigarettes in the client's room. Which intervention is most important
for the nurse to implement? - Answer Remove cigarettes for the client's room
A young adult client is admitted to the emergency room following a motor vehicle
collision. The client's head hit the dashboard. Admission assessment include:
Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and
respirations 22 breath/minute. Based on these data, the nurse formulates the
,first portion of nursing diagnosis as " Risk of injury" What term best expresses the
"related to" portion of nursing diagnosis?
A.)Infection
B.)Increase intracranial pressure
C.)Shock
D.)Head Injury. - Answer C
An older male client with history of diabetes mellitus, chronic gout, and
osteoarthritis comes to the clinic with a bag of medication bottles. Which
intervention should the nurse implement first? - Answer Identify pills in the bag.
A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the
clinic complaining of weakness and fatigue. Which finding is most important for
the nurse to report to the healthcare provider? - Answer New onset of purple skin
lesions.
,In assessing a client twelve hours following transurethral resection of the prostate
(TURP), the nurse observes that the urinary drainage tubing contains a large
amount of clear pale pink urine and the continuous bladder irrigation is infusing
slowly. What action should the nurse implement? - Answer Ensure that no
dependent loops are present in the tubing.
The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg
PO every 12 h for a client with postoperative wound infections. Which feeds
should the nurse encourage this client to eat?
A.)Yogurt and/or buttermilk.
B.)Avocados and cheese
C.)Green leafy vegetables
D.)Fresh fruits - Answer A
The charge nurse is making assignment on a psychiatric unit for a practical nurse
(PN) and newly license register nurse (RN). Which client should be assigned to the
RN?
, A.)An adult female who has been depress for the past several month and denies
suicidal ideations.
B.)A middle-age male who is in depressive phase on bipolar disease and is
receiving Lithium.
C.)A young male with schizophrenia who said voices is telling him to kill his
psychiatric.
D.)An elderly male who tell the staff and other client that he is superman and he
can fly. - Answer C
In assessing an older female client with complication associated with chronic
obstructive pulmonary disease (COPD), the nurse notices a change in the client's
appearance. Her face appears tense and she begs the nurse not to leave her
alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary
nursing diagnosis? - Answer Anxiety related to fear of suffocation.
A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal
traction applied as a method of closed reduction. Which intervention is most
important for the nurse to include in the client's a plan of care? - Answer Provide
daily care of tong insertion sites using saline and antibiotic ointment
Questions with complete
solutions.
Suicide precautions are initiated for a child admitted to the mental health unit
following an intentional narcotic overdose. After a visitor leaves, the nurse finds a
package of cigarettes in the client's room. Which intervention is most important
for the nurse to implement? - Answer Remove cigarettes for the client's room
A young adult client is admitted to the emergency room following a motor vehicle
collision. The client's head hit the dashboard. Admission assessment include:
Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and
respirations 22 breath/minute. Based on these data, the nurse formulates the
,first portion of nursing diagnosis as " Risk of injury" What term best expresses the
"related to" portion of nursing diagnosis?
A.)Infection
B.)Increase intracranial pressure
C.)Shock
D.)Head Injury. - Answer C
An older male client with history of diabetes mellitus, chronic gout, and
osteoarthritis comes to the clinic with a bag of medication bottles. Which
intervention should the nurse implement first? - Answer Identify pills in the bag.
A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the
clinic complaining of weakness and fatigue. Which finding is most important for
the nurse to report to the healthcare provider? - Answer New onset of purple skin
lesions.
,In assessing a client twelve hours following transurethral resection of the prostate
(TURP), the nurse observes that the urinary drainage tubing contains a large
amount of clear pale pink urine and the continuous bladder irrigation is infusing
slowly. What action should the nurse implement? - Answer Ensure that no
dependent loops are present in the tubing.
The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg
PO every 12 h for a client with postoperative wound infections. Which feeds
should the nurse encourage this client to eat?
A.)Yogurt and/or buttermilk.
B.)Avocados and cheese
C.)Green leafy vegetables
D.)Fresh fruits - Answer A
The charge nurse is making assignment on a psychiatric unit for a practical nurse
(PN) and newly license register nurse (RN). Which client should be assigned to the
RN?
, A.)An adult female who has been depress for the past several month and denies
suicidal ideations.
B.)A middle-age male who is in depressive phase on bipolar disease and is
receiving Lithium.
C.)A young male with schizophrenia who said voices is telling him to kill his
psychiatric.
D.)An elderly male who tell the staff and other client that he is superman and he
can fly. - Answer C
In assessing an older female client with complication associated with chronic
obstructive pulmonary disease (COPD), the nurse notices a change in the client's
appearance. Her face appears tense and she begs the nurse not to leave her
alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary
nursing diagnosis? - Answer Anxiety related to fear of suffocation.
A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal
traction applied as a method of closed reduction. Which intervention is most
important for the nurse to include in the client's a plan of care? - Answer Provide
daily care of tong insertion sites using saline and antibiotic ointment
