Hesi Management Exam Questions With Complete Solutions
4 C's of communication in delegation Correct Answers clear
concise
correct
complete
A 32-year-old patient with sickle cell anemia is admitted to the
hospital during a sickle cell crisis. Which action prescribed by
the health care provider will you implement first? Correct
Answers Administer 100% oxygen using a nonrebreather mask.
Hypoxia and deoxygenation of the RBCs are the most common
cause of sickling, so administration of oxygen is the priority
intervention here. Pain control and hydration are also important
interventions for this patient and should be accomplished
rapidly. Vaccination may help prevent future sickling episodes
by decreasing the risk of infection, but it will not help with the
current sickling crisis.
A 67-year-old who is receiving chemotherapy for lung cancer is
admitted to the hospital with thrombocytopenia. Which
statement made by the patient when you are obtaining the
admission history is of most concern? Correct Answers "I take
one aspirin every morning because of my history of angina."
Because aspirin will decrease platelet aggregation, patients with
thrombocytopenia should not use aspirin routinely. Patient
teaching about this should be included in the care plan. Bruising
is consistent with the patient's admission problem of
thrombocytopenia. Soft, dark brown stools indicate that there is
,no frank blood in the bowel movements. Although the patient's
decreased appetite requires further assessment by the nurse, this
is a common complication of chemotherapy.
A client has been diagnosed with disseminated herpes zoster.
Which personal protective equipment (PPE) will you need to put
on when preparing to assess the client? (Select all that apply.)
Correct Answers Because herpes zoster (shingles) is spread
through airborne means and by direct contact with the lesions,
you should wear an N95 respirator or high-efficiency particulate
air filter respirator, a gown, and gloves. Surgical face masks
filter only large particles and will not provide protection from
herpes zoster. Goggles and shoe covers are not needed for
airborne or contact precautions.
A client is crying and grimacing but denies pain and refuses pain
medication, because "my sibling is a drug addict and has ruined
our lives." What is the priority intervention for this client?
Correct Answers Encourage expression of fears and past
experiences.
This client has strong beliefs and emotions related to the issue of
the sibling's addiction. First, encourage expression. This
indicates to the client that the feelings are real and valid. It is
also an opportunity to assess beliefs and fears. Giving facts and
information is appropriate at the right time. Family involvement
is important, but it should be kept in mind that their beliefs
about drug addiction may be similar to those of the client.
A client reports a sudden excruciating pain in the left eye with
the visual change of colored halos around lights and blurred
,vision. Which interventions should you anticipate and perform
for this emergency condition? (Select all that apply.) Correct
Answers Instill a miotic agent, such as pilocarpine (Isopto
Carpine).
Administer an oral hyperosmotic agent, such as isosorbide
(Ismotic).
Apply a cool compress to the forehead.
Provide a darkened, quiet, and private space for the client.
The client's symptoms are suggestive of angle-closure
glaucoma. Immediate inventions include instillation of miotics,
which open the trabecular network and facilitate aqueous
outflow, and intravenous or oral administration of hyperosmotic
agents to move fluid from the intracellular space to the
extracellular space. Applying cool compresses and providing a
dark, quiet space are appropriate comfort measures.
Photodynamic therapy is a treatment for age-related macular
degeneration. Use of mydriatics is contraindicated because
dilation of the pupil will further block the outflow.
A client underwent an exploratory laparotomy 2 days ago. The
physician should be called immediately for which physical
assessment finding? Correct Answers Abdominal distention
and rigidity
Distention and rigidity can signal hemorrhage or peritonitis. The
physician may also decide that these symptoms require a
medication to stimulate peristalsis. Absence of bowel sounds is
, expected within the first 24 to 48 hours. Nausea and vomiting
are not uncommon and are usually self-limiting, and an "as
needed" (PRN) order for an antiemetic is usually part of the
routine postoperative orders. The reason for displacement of the
NG tube should be assessed and the tube secured as necessary.
A client who recently started taking phenytoin to control simple
partial seizures is seen in the outpatient clinic. Which
information obtained during her chart review and assessment
will be of greatest concern? Correct Answers The white blood
cell count is 2300/mm3.
Leukopenia is a serious adverse effect of phenytoin therapy and
would require discontinuation of the medication. The other data
indicate a need for further assessment and/or client teaching but
will not require a change in medical treatment for the seizures.
A client who states that he may have been contaminated by
anthrax arrives at the ED. Which action included in the ED
protocol for possible anthrax exposure will you take first?
Correct Answers Escort the client to a decontamination room.
To prevent contamination of staff or other clients by anthrax,
decontamination of the client by removal and disposal of
clothing and showering is the initial action in possible anthrax
exposure. Assessment of the client for signs of infection should
be performed after decontamination. Notification of security
personnel (and local and regional law enforcement agencies) is
necessary in the case of possible bioterrorism, but this should
occur after decontaminating and caring for the client. According
to the CDC guidelines, antibiotics should be administered only if
4 C's of communication in delegation Correct Answers clear
concise
correct
complete
A 32-year-old patient with sickle cell anemia is admitted to the
hospital during a sickle cell crisis. Which action prescribed by
the health care provider will you implement first? Correct
Answers Administer 100% oxygen using a nonrebreather mask.
Hypoxia and deoxygenation of the RBCs are the most common
cause of sickling, so administration of oxygen is the priority
intervention here. Pain control and hydration are also important
interventions for this patient and should be accomplished
rapidly. Vaccination may help prevent future sickling episodes
by decreasing the risk of infection, but it will not help with the
current sickling crisis.
A 67-year-old who is receiving chemotherapy for lung cancer is
admitted to the hospital with thrombocytopenia. Which
statement made by the patient when you are obtaining the
admission history is of most concern? Correct Answers "I take
one aspirin every morning because of my history of angina."
Because aspirin will decrease platelet aggregation, patients with
thrombocytopenia should not use aspirin routinely. Patient
teaching about this should be included in the care plan. Bruising
is consistent with the patient's admission problem of
thrombocytopenia. Soft, dark brown stools indicate that there is
,no frank blood in the bowel movements. Although the patient's
decreased appetite requires further assessment by the nurse, this
is a common complication of chemotherapy.
A client has been diagnosed with disseminated herpes zoster.
Which personal protective equipment (PPE) will you need to put
on when preparing to assess the client? (Select all that apply.)
Correct Answers Because herpes zoster (shingles) is spread
through airborne means and by direct contact with the lesions,
you should wear an N95 respirator or high-efficiency particulate
air filter respirator, a gown, and gloves. Surgical face masks
filter only large particles and will not provide protection from
herpes zoster. Goggles and shoe covers are not needed for
airborne or contact precautions.
A client is crying and grimacing but denies pain and refuses pain
medication, because "my sibling is a drug addict and has ruined
our lives." What is the priority intervention for this client?
Correct Answers Encourage expression of fears and past
experiences.
This client has strong beliefs and emotions related to the issue of
the sibling's addiction. First, encourage expression. This
indicates to the client that the feelings are real and valid. It is
also an opportunity to assess beliefs and fears. Giving facts and
information is appropriate at the right time. Family involvement
is important, but it should be kept in mind that their beliefs
about drug addiction may be similar to those of the client.
A client reports a sudden excruciating pain in the left eye with
the visual change of colored halos around lights and blurred
,vision. Which interventions should you anticipate and perform
for this emergency condition? (Select all that apply.) Correct
Answers Instill a miotic agent, such as pilocarpine (Isopto
Carpine).
Administer an oral hyperosmotic agent, such as isosorbide
(Ismotic).
Apply a cool compress to the forehead.
Provide a darkened, quiet, and private space for the client.
The client's symptoms are suggestive of angle-closure
glaucoma. Immediate inventions include instillation of miotics,
which open the trabecular network and facilitate aqueous
outflow, and intravenous or oral administration of hyperosmotic
agents to move fluid from the intracellular space to the
extracellular space. Applying cool compresses and providing a
dark, quiet space are appropriate comfort measures.
Photodynamic therapy is a treatment for age-related macular
degeneration. Use of mydriatics is contraindicated because
dilation of the pupil will further block the outflow.
A client underwent an exploratory laparotomy 2 days ago. The
physician should be called immediately for which physical
assessment finding? Correct Answers Abdominal distention
and rigidity
Distention and rigidity can signal hemorrhage or peritonitis. The
physician may also decide that these symptoms require a
medication to stimulate peristalsis. Absence of bowel sounds is
, expected within the first 24 to 48 hours. Nausea and vomiting
are not uncommon and are usually self-limiting, and an "as
needed" (PRN) order for an antiemetic is usually part of the
routine postoperative orders. The reason for displacement of the
NG tube should be assessed and the tube secured as necessary.
A client who recently started taking phenytoin to control simple
partial seizures is seen in the outpatient clinic. Which
information obtained during her chart review and assessment
will be of greatest concern? Correct Answers The white blood
cell count is 2300/mm3.
Leukopenia is a serious adverse effect of phenytoin therapy and
would require discontinuation of the medication. The other data
indicate a need for further assessment and/or client teaching but
will not require a change in medical treatment for the seizures.
A client who states that he may have been contaminated by
anthrax arrives at the ED. Which action included in the ED
protocol for possible anthrax exposure will you take first?
Correct Answers Escort the client to a decontamination room.
To prevent contamination of staff or other clients by anthrax,
decontamination of the client by removal and disposal of
clothing and showering is the initial action in possible anthrax
exposure. Assessment of the client for signs of infection should
be performed after decontamination. Notification of security
personnel (and local and regional law enforcement agencies) is
necessary in the case of possible bioterrorism, but this should
occur after decontaminating and caring for the client. According
to the CDC guidelines, antibiotics should be administered only if
