HESI 799 RN Exit Exam
,A client on a long-term mental health unit repeatedly takes own pulse regardless of the
circumstance. What action should the nurse implement?
a. Overlook the client's behavior.
b. Distract client to interfere with the ritual.
c. Ask why the client checks the pulse.
d. Hold client's hand to stop the behavior. - CORRECT ANSWERS-Overlook the client's
behavior.
A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which
instructions should the nurse include?
a. Wash hands before cleaning exit site
b. Keep the head of the bed flat at night
c. Feel for a thrill and a distal pulse nightly
d. Do not get up if fluid is left in the abdomen - CORRECT ANSWERS-Wash hands
before cleaning exit site
Rationale: meticulous hand hygiene is essential when performing care for a peritoneal
dialysis, infections is a common complication of peritoneal dialysis.
The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation
for performing a sterile dressing change. Which action by the PN requires correction by
the charge nurse?
a- Opening the package
b- Picking up the second glove
c- Picking up the first glove
d- Positioning of the table - CORRECT ANSWERS-Picking up the second glove
A young adult who is hit with a baseball bat on the temporal area of the left skull is
conscious when admitted to the ED and is transferred to the Neurological Unit to be
monitored for signs of closed head injury. Which assessment finding is indicative of a
developing epidural hematoma?
a. Altered consciousness within the first 24 hours after injury.
b. Cushing reflex and cerebral edema after 24 hours
c. Fever, nuchal rigidity and opisthotonos within hours
d. Headache and pupillary changes 48 hours after a head injury - CORRECT
ANSWERS-Altered consciousness within the first 24 hours after injury.
A male client reports to the clinic nurse that he has been feeling well and is often "dizzy"
his blood pressure is elevated. Based on this findings, this client is at a greatest risk for
which pathophysiological condition?
, a. Pulmonary hypertension
b. Left ventricular hypertrophy
c. Renal failure
d. Stroke - CORRECT ANSWERS-Stroke
The nurse ask the parent to stay during the examination of a male toddler's genital area.
Which intervention should the nurse implement?
a. Examine the genitalia as the last part of the total exam.
b. Use soothing statements to facilitate cooperation
c. Allow the child to keep underpants on to examine genitalia
d. Work slowly and methodically so not to stress the child - CORRECT ANSWERS-
Examine the genitalia as the last part of the total exam.
Rationale: Examination of a child's genitalia is particularly stressful to toddles, so this
assessment is best left as the last part of the examination. B are best done by a parent,
not the nurse. The genitals must be completely visualized and sometimes palpates
underwear for a brief period of.
The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing
setup when the bag of solution is _____. Which action should the nurse take to ensure
adequate filling of the drip chamber?
a. Lower the IV bag to a flat surface
b. Compress the drip chamber
c. Open the roller clamp
d. Squeeze the bag of IV solution - CORRECT ANSWERS-Compress the drip chamber
During an Insulin infusion for a client with diabetes mellitus who is experiencing
hyperglycemic hyperosmolar syndrome in addition to the client's glucose, which
laboratory value is most important for the nurse to monitor?
a. Urine ketones
b. Urine albumin
c. Serum protein
d. Serum potassium - CORRECT ANSWERS-d. Serum potassium
Rationale: Electrolyte shifts are common during correction of hyperosmolar and
hyperglycemic states. Monitor electrolyte levels at least every 4 hours, or every 2 hours
if needed. Monitor serum sodium and potassium levels closely. If needed, use isotonic
and hypotonic saline solutions to adjust the patient's sodium level. Despite major
potassium loss during diuresis in early HHS stages, many patients initially present in a
hyperkalemic state due to dehydration. When fluid and insulin therapy begin, the serum
potassium level may drop dramatically.
,A client on a long-term mental health unit repeatedly takes own pulse regardless of the
circumstance. What action should the nurse implement?
a. Overlook the client's behavior.
b. Distract client to interfere with the ritual.
c. Ask why the client checks the pulse.
d. Hold client's hand to stop the behavior. - CORRECT ANSWERS-Overlook the client's
behavior.
A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which
instructions should the nurse include?
a. Wash hands before cleaning exit site
b. Keep the head of the bed flat at night
c. Feel for a thrill and a distal pulse nightly
d. Do not get up if fluid is left in the abdomen - CORRECT ANSWERS-Wash hands
before cleaning exit site
Rationale: meticulous hand hygiene is essential when performing care for a peritoneal
dialysis, infections is a common complication of peritoneal dialysis.
The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation
for performing a sterile dressing change. Which action by the PN requires correction by
the charge nurse?
a- Opening the package
b- Picking up the second glove
c- Picking up the first glove
d- Positioning of the table - CORRECT ANSWERS-Picking up the second glove
A young adult who is hit with a baseball bat on the temporal area of the left skull is
conscious when admitted to the ED and is transferred to the Neurological Unit to be
monitored for signs of closed head injury. Which assessment finding is indicative of a
developing epidural hematoma?
a. Altered consciousness within the first 24 hours after injury.
b. Cushing reflex and cerebral edema after 24 hours
c. Fever, nuchal rigidity and opisthotonos within hours
d. Headache and pupillary changes 48 hours after a head injury - CORRECT
ANSWERS-Altered consciousness within the first 24 hours after injury.
A male client reports to the clinic nurse that he has been feeling well and is often "dizzy"
his blood pressure is elevated. Based on this findings, this client is at a greatest risk for
which pathophysiological condition?
, a. Pulmonary hypertension
b. Left ventricular hypertrophy
c. Renal failure
d. Stroke - CORRECT ANSWERS-Stroke
The nurse ask the parent to stay during the examination of a male toddler's genital area.
Which intervention should the nurse implement?
a. Examine the genitalia as the last part of the total exam.
b. Use soothing statements to facilitate cooperation
c. Allow the child to keep underpants on to examine genitalia
d. Work slowly and methodically so not to stress the child - CORRECT ANSWERS-
Examine the genitalia as the last part of the total exam.
Rationale: Examination of a child's genitalia is particularly stressful to toddles, so this
assessment is best left as the last part of the examination. B are best done by a parent,
not the nurse. The genitals must be completely visualized and sometimes palpates
underwear for a brief period of.
The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing
setup when the bag of solution is _____. Which action should the nurse take to ensure
adequate filling of the drip chamber?
a. Lower the IV bag to a flat surface
b. Compress the drip chamber
c. Open the roller clamp
d. Squeeze the bag of IV solution - CORRECT ANSWERS-Compress the drip chamber
During an Insulin infusion for a client with diabetes mellitus who is experiencing
hyperglycemic hyperosmolar syndrome in addition to the client's glucose, which
laboratory value is most important for the nurse to monitor?
a. Urine ketones
b. Urine albumin
c. Serum protein
d. Serum potassium - CORRECT ANSWERS-d. Serum potassium
Rationale: Electrolyte shifts are common during correction of hyperosmolar and
hyperglycemic states. Monitor electrolyte levels at least every 4 hours, or every 2 hours
if needed. Monitor serum sodium and potassium levels closely. If needed, use isotonic
and hypotonic saline solutions to adjust the patient's sodium level. Despite major
potassium loss during diuresis in early HHS stages, many patients initially present in a
hyperkalemic state due to dehydration. When fluid and insulin therapy begin, the serum
potassium level may drop dramatically.
