HESI 1 EXIT RN V4 QUESTIONS & ANSWERS

1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? - Make certain the child is maintained in correct body alignment 2. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider? - Height and weight percentiles vary widely 3. . The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? - advise the parents to ignore breath holding because breathing will begin as a reflex 4. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? - My pain is deep in my chest behind my sternum 5. Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? - checking the clients blood pressure 6. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? - "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." 7. 2-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: - Ask the answering service to contact the on-call physician 8. An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: - Ask the ED physician to check the client 9. NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: - Administer the antihypertensive with a small sip of water 10. A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? - " Tell me more about what you're feeling" 11. A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse's priority? - contacting the physician 12. A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: - Call the radiography department to obtain a chest x-ray 13. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? - Safety 14. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? - They are able to think logically in organizing facts 15. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to - An occupational therapist from the community center 16. A priority goal of involuntary hospitalization of the severely mentally ill client is - Protection from harm to self or others 17. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend - isometric 18. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report - Loss of consciousness 19. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would - Administer a laxative to the client the evening before the examination 20. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? - Risk for infection 21. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that - Circumcision is delayed so the foreskin can be used for the surgical repair 22. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? - Shallow Respiration 23. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse's best explanation of these findings? - These side effects are common and should subside in a few days 24. A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse? - Ask the client if he has noticed any bleeding or dark stools 25. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the - Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow 26. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? - Institute seizure precautions 27. Following mitral valve replacement surgery a client develops PVC's. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc's of D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute? - 60microdrops/minute 28. The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's Syndrome? - Varicella 29. While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocial skill? - Assertion of control 30. A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome? - Cranial facial abnormalities are noted 31. The nurse is attending a workshop about caring for persons infected with Hepatitis. Which statement is correct when referring to the incidence rate for Hepatitis? - The number of persons in a population who develop Hepatitis B during a specific period of time 32. A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client? - Capillary refill less than 3 seconds The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? - Sputum culture 34. The nurse has been teaching an apprehensive primipara who has difficulty in initial nursing of the newborn. What observation at the time of discharge suggests that initial breast feeding is effective? - The mother feels calmer and talks to the baby while nursing 35. The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is - "All layers of the skin were destroyed in the burn." 36. The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered - Rude 37. A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child? - Eating peanuts 38. When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by - An imbalance between red cell destruction and production 39. The nurse is assessing a newborn delivered at home by an admitted heroin addict. Which of the following would the nurse expect to observe? - Jitteriness at 24-48 hours 40. The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention? - Pulse oximetry of 85% 41. The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body? - Inspect the skin 42. Which action is most likely to ensure the safety of the nurse while making a home visit? - Remain alert at all times and leave if cues suggest the home is not safe 43. An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by - Tachypnea 44. The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: "We are concerned about the possible occurrence of sudden infant death syndrome (SIDS)." In order to take appropriate action, the nurse must understand that - 95% of SIDS cases occur before 6 months of age 45. As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid - Scuba Diving 46. The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be - High calorie, high protein, unrestricted fat 47. A client had arrived in the USA from a developing country 1 week prior. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS with a history of unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of - Acute tuberculosis with a productive cough of discolored sputum for over three months 48. A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client? - Poor skin turgor 49. When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend? - Deep Breathing 50. When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in? - Playing cooperatively with other preschoolers 51. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding? - Hold a rattle 52. When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child? - Explain the surgery using a model of the heart 53. The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments? - Accept their feeling without judgement 54. When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? - Sterile technique for dressing change at IV site 55. When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery after a myocardial infarction, which finding would be of greatest concern to the nurse? - Hematemesis 56. A 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion was initiated, the client complains of chills and headache. Which action should the nurse implement first? - Stop the transfusion 57. An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which order should be questioned by the nurse? - Aspirin for pain management 58. The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching? - "The therapy can be discontinued when the spots disappear." 59. The nurse is preparing a client for discharge following in-patient treatment for pulmonary tuberculosis. Which of these instructions should be given to the client? - Continue medication use as prescribed 60. The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's immediate attention? - "I am itching all over." 61. A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the treatment. What should the nurse discuss with the client as part of the teaching plan? - Avoidance of alcohol 62. The nurse prepares to administer eye drops to a 6 year-old child. Which of these demonstrates the correct method for instillation of eye drops? - In the conjunctival sac as the lower lid is pulled down 63. A depressed client is experiencing severe insomnia. The health care provider orders trazadone (Desyrel). The nurse tells the client to expect - Relief of insomnia 64. A client with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client's symptoms of excessive hunger and thirst, what would the nurse expect the health care provider to order? - Regular insulin