EXIT HESI - COMPREHENSIVE PN EXAM A QUESTIONS
WITH DETAILED VERIFIED ANSWERS (100% CORRECT
ANSWERS) /ALREADY GRADED A+
A nurse who has recently completed orientation is beginning work in the labor and delivery unit
for the first time. When making assignments, which client should the charge nurse assign to this
new nurse? - ✔✔ - A multiparous client who is dilated 5 cm and 50% effaced
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ)
PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum
potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? - ✔✔ -
The client's renal function has affected his potassium level.
A registered nurse (RN) delivers telehealth services to clients via electronic communication.
Which nursing action creates the greatest risk for professional liability and has the potential for a
malpractice lawsuit? - ✔✔ - Sending medical records to health care providers via the Internet
Which pathophysiologic response supports the contraindication for opioids, such as morphine, in
clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. - ✔✔
-D
The greatest risk associated with opioids such as morphine (D) is respiratory depression that
causes an increase in Pco2, which increases ICP and masks the early signs of intracranial
bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a
client with increased ICP.
,A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity
that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and
swallow. Which information is most important for the nurse to provide the client? - ✔✔ - Oral
hygiene should be performed before the medication.
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client? - ✔✔ - Sitting upright and forward with both arms supported
on an over the bed table
A male client is admitted for observation after being hit on the head with a baseball bat. Six
hours after admission, the client attempts to crawl out of bed and asks the nurse why there are so
many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on room
air. Which intervention should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed. - ✔✔ - C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental status (C).
It is important to act early and quickly when symptoms of increased ICP occur. Because his
oxygen saturation is normal, the administration of oxygen (A) is not the top priority. Vital signs
should be monitored frequently (B), but the client's confusion should be reported immediately.
(D) is not a useful intervention.
The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam
hydrochloride (Versed). In assessing the client, the nurse determines that the client has slurred
speech with diplopia. Based on this finding, what action should the nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
D.Continue to monitor the client. - ✔✔ - D
, The desired level III in conscious sedation includes slurred speech, glazed eyes, and marked
diplopia. Because this is the desired outcome of the medication regimen, no action is needed but
continuing to monitor the client (D). The airway is open if the client is able to talk (A). There are
no signs of hypoglycemia (B). No reversal is necessary for the benzodiazepine (Versed) without
signs of oversedation, such as respiratory depression (C).
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are
not yet known. Which instruction should the charge nurse give to the other staff members at this
time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received. - ✔✔ - D
When faced with an impending disaster, hospital personnel may be alerted but should continue
with current client care assignments until further instructions are received (D). Evacuation is
typically a response of last resort that begins with clients who are most able to ambulate (A). (B)
is premature and is likely to increase the chaos if incoming casualties are anticipated. (C) is poor
utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The client's vital
signs change suddenly, and the nurse determines that the client's condition is worsening. The
nurse is unsure of the client's resuscitative status and needs to check the client's medical record
for any advanced directives. Which action should the nurse implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the advanced directive.
C.Check the medical record for the advanced directive and then complete the client assessment.
D.Call for the charge nurse to check the advanced directive while continuing to assess the client.
- ✔✔ - D
WITH DETAILED VERIFIED ANSWERS (100% CORRECT
ANSWERS) /ALREADY GRADED A+
A nurse who has recently completed orientation is beginning work in the labor and delivery unit
for the first time. When making assignments, which client should the charge nurse assign to this
new nurse? - ✔✔ - A multiparous client who is dilated 5 cm and 50% effaced
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ)
PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum
potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? - ✔✔ -
The client's renal function has affected his potassium level.
A registered nurse (RN) delivers telehealth services to clients via electronic communication.
Which nursing action creates the greatest risk for professional liability and has the potential for a
malpractice lawsuit? - ✔✔ - Sending medical records to health care providers via the Internet
Which pathophysiologic response supports the contraindication for opioids, such as morphine, in
clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. - ✔✔
-D
The greatest risk associated with opioids such as morphine (D) is respiratory depression that
causes an increase in Pco2, which increases ICP and masks the early signs of intracranial
bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a
client with increased ICP.
,A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity
that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and
swallow. Which information is most important for the nurse to provide the client? - ✔✔ - Oral
hygiene should be performed before the medication.
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client? - ✔✔ - Sitting upright and forward with both arms supported
on an over the bed table
A male client is admitted for observation after being hit on the head with a baseball bat. Six
hours after admission, the client attempts to crawl out of bed and asks the nurse why there are so
many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on room
air. Which intervention should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed. - ✔✔ - C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental status (C).
It is important to act early and quickly when symptoms of increased ICP occur. Because his
oxygen saturation is normal, the administration of oxygen (A) is not the top priority. Vital signs
should be monitored frequently (B), but the client's confusion should be reported immediately.
(D) is not a useful intervention.
The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam
hydrochloride (Versed). In assessing the client, the nurse determines that the client has slurred
speech with diplopia. Based on this finding, what action should the nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
D.Continue to monitor the client. - ✔✔ - D
, The desired level III in conscious sedation includes slurred speech, glazed eyes, and marked
diplopia. Because this is the desired outcome of the medication regimen, no action is needed but
continuing to monitor the client (D). The airway is open if the client is able to talk (A). There are
no signs of hypoglycemia (B). No reversal is necessary for the benzodiazepine (Versed) without
signs of oversedation, such as respiratory depression (C).
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are
not yet known. Which instruction should the charge nurse give to the other staff members at this
time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received. - ✔✔ - D
When faced with an impending disaster, hospital personnel may be alerted but should continue
with current client care assignments until further instructions are received (D). Evacuation is
typically a response of last resort that begins with clients who are most able to ambulate (A). (B)
is premature and is likely to increase the chaos if incoming casualties are anticipated. (C) is poor
utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The client's vital
signs change suddenly, and the nurse determines that the client's condition is worsening. The
nurse is unsure of the client's resuscitative status and needs to check the client's medical record
for any advanced directives. Which action should the nurse implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the advanced directive.
C.Check the medical record for the advanced directive and then complete the client assessment.
D.Call for the charge nurse to check the advanced directive while continuing to assess the client.
- ✔✔ - D
