Exit Hesi 700 + Bank 101-200
1. 101. A client presents in the emergency room with right-sided facial asym- metry.
The nurse asks the client to perform a series of movements that require use of the facial
muscles. What symptoms suggest that the client has most likely experience a Bells
palsy rather than a stroke?
a- Slow onset of facial drooping associated with headache
b- Inability to close the affected eye, raise brow, or smile
c- A flat nasolabial fold on the right resulting in facial
asymmetry.
d- Drooling is present on right side of the mouth, but not on the left Ans Ans: b-
Inability to close the affected eye, raise brow, or smile
Rationale: Because the motor function controlling eye closure, brow movement and
smiling are all carried on the 7th cranial (facial) nerve, the combination of symptoms
directly relating to an impairment of all branches of the facial nerve indicate that Bell s
palsy has occurred.
2. 102. The nurse is teaching a client how to perform colostomy irrigations. When
observing the client's return demonstration, which action indicated that the client
understood the teaching?
a- Turns to left the side to instill the irrigating solution into the stoma
b- Keeps the irrigating container less than 18 inches above the stoma
,c- Instills 1,200 ml of irrigating solution to stimulate bowel evacuation
d- Inserts irrigating catheter deeper into stoma when cramping occurs Ans: b-
Keeps the irrigating container less than 18 inches above the stoma
Rationale: Keeping the irrigating container less than 18 inches above the stoma permits
the solution to flow slowly with little excessive peristalsis does not cause immediate
release of stool.
3. 103. The nurse should teach the client to observe which precaution while taking
dronedarone?
a- Stay out of direct sunlight
, Exit Hesi 700 + Bank 101-200
Study online at https Ans: //quizlet.com/_ewbg8e
b- Avoid grapefruits and its juice
c- Reduce the use of herbal supplements
d- Minimize sodium intake Ans Ans: b- Avoid grapefruits and its juice
Rationale: Grapefruit increase the effect of dronedarone thereby increasing the possibility
of serious side effects. A does not cause a serious effect. C may potentiate lethal arrhythmias
and should be avoided. D does not directly affect those taking dronedarone.
4. 104. A client who sustained a head injury following an automobile collision is
admitted to the hospital. The nurse includes the client's risk for developing increased
intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that
ICP has increased?
a- Increased Glasgow coma scale score
b- Nuchal rigidity and papilledema
c- Confusion and papilledema
d- Periorbital ecchymosis Ans Ans: c- Confusion and papilledema
Rationale: papilledema is always an indicator of increased ICP, and confusion is usually
the first sign of increased ICP. Other options do not necessarily reflect increased ICP.
5. 105. The nurse is caring for a client receiving continuous IV fluids through a single
lumen central venous catheter (CVC). Based on the CVC care bundle, which action
should be completed daily to reduce the risk for infection?
, Exit Hesi 700 + Bank 101-200
Study online at https Ans: //quizlet.com/_ewbg8e
a- Remind staff to follow protective environment precautions
b- Gently flush the catheter lumen with sterile saline solution
c- Cleanse the site and change the transparent dressing
d- Confirm the necessity for continued use of the CVC Ans: d- Confirm the necessity for
continued use of the CVC
1. 101. A client presents in the emergency room with right-sided facial asym- metry.
The nurse asks the client to perform a series of movements that require use of the facial
muscles. What symptoms suggest that the client has most likely experience a Bells
palsy rather than a stroke?
a- Slow onset of facial drooping associated with headache
b- Inability to close the affected eye, raise brow, or smile
c- A flat nasolabial fold on the right resulting in facial
asymmetry.
d- Drooling is present on right side of the mouth, but not on the left Ans Ans: b-
Inability to close the affected eye, raise brow, or smile
Rationale: Because the motor function controlling eye closure, brow movement and
smiling are all carried on the 7th cranial (facial) nerve, the combination of symptoms
directly relating to an impairment of all branches of the facial nerve indicate that Bell s
palsy has occurred.
2. 102. The nurse is teaching a client how to perform colostomy irrigations. When
observing the client's return demonstration, which action indicated that the client
understood the teaching?
a- Turns to left the side to instill the irrigating solution into the stoma
b- Keeps the irrigating container less than 18 inches above the stoma
,c- Instills 1,200 ml of irrigating solution to stimulate bowel evacuation
d- Inserts irrigating catheter deeper into stoma when cramping occurs Ans: b-
Keeps the irrigating container less than 18 inches above the stoma
Rationale: Keeping the irrigating container less than 18 inches above the stoma permits
the solution to flow slowly with little excessive peristalsis does not cause immediate
release of stool.
3. 103. The nurse should teach the client to observe which precaution while taking
dronedarone?
a- Stay out of direct sunlight
, Exit Hesi 700 + Bank 101-200
Study online at https Ans: //quizlet.com/_ewbg8e
b- Avoid grapefruits and its juice
c- Reduce the use of herbal supplements
d- Minimize sodium intake Ans Ans: b- Avoid grapefruits and its juice
Rationale: Grapefruit increase the effect of dronedarone thereby increasing the possibility
of serious side effects. A does not cause a serious effect. C may potentiate lethal arrhythmias
and should be avoided. D does not directly affect those taking dronedarone.
4. 104. A client who sustained a head injury following an automobile collision is
admitted to the hospital. The nurse includes the client's risk for developing increased
intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that
ICP has increased?
a- Increased Glasgow coma scale score
b- Nuchal rigidity and papilledema
c- Confusion and papilledema
d- Periorbital ecchymosis Ans Ans: c- Confusion and papilledema
Rationale: papilledema is always an indicator of increased ICP, and confusion is usually
the first sign of increased ICP. Other options do not necessarily reflect increased ICP.
5. 105. The nurse is caring for a client receiving continuous IV fluids through a single
lumen central venous catheter (CVC). Based on the CVC care bundle, which action
should be completed daily to reduce the risk for infection?
, Exit Hesi 700 + Bank 101-200
Study online at https Ans: //quizlet.com/_ewbg8e
a- Remind staff to follow protective environment precautions
b- Gently flush the catheter lumen with sterile saline solution
c- Cleanse the site and change the transparent dressing
d- Confirm the necessity for continued use of the CVC Ans: d- Confirm the necessity for
continued use of the CVC
