HESI 799 RN Exit Exam (Josh's Version)
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PRIMARY COMPREHENSIVE EXAM |! |! |!
WITH ACCURATYE DETAILED |! |! |!
ANSWERS
1.The nurse observes an unlicensed assistive personnel (UAP)
|! |! |! |! |! |! |! |!
positioning a newly admitted client who has a seizure disorder. The
|! |! |! |! |! |! |! |! |! |! |!
client is supine and the UAP is placing soft pillows along the side
|! |! |! |! |! |! |! |! |! |! |! |! |!
rails. What action should the nurse implement?
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a. Ensure that the UAP has placed the pillows effectively to protect
|! |! |! |! |! |! |! |! |! |! |!
the client. |!
b. Instruct the UAP to obtain soft blankets to secure to the side
|! |! |! |! |! |! |! |! |! |! |! |!
rails instead of pillows.
|! |! |!
c. Assume responsibility for placing the pillows while the UAP
|! |! |! |! |! |! |! |! |!
completes another task. |! |!
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,d. Ask the UAP to use some of the pillows to prop the client in a
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
side lying position.: Instruct the UAP to obtain soft blankets to
|! |! |! |! |! |! |! |! |! |! |!
secure to the side rails instead of pillows
|! |! |! |! |! |! |!
Rationale: The nurse should instruct the UAP to pad the side rails
|! |! |! |! |! |! |! |! |! |! |! |!
with soft blankest because the use of pillows could result in
|! |! |! |! |! |! |! |! |! |! |!
suffocation and would need to be removed at the onset of the |! |! |! |! |! |! |! |! |! |! |! |!
seizure. The nurse can delegate paddling the side rails to the
|! |! |! |! |! |! |! |! |! |! |!
UAP
2.A 60-year-old female client with a positive family history of
|! |! |! |! |! |! |! |! |! |!
ovarian cancer has developed an abdominal mass and is being
|! |! |! |! |! |! |! |! |! |!
evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear
|! |! |! |! |! |! |! |!
|! results are negative. What information should the nurse include in
|! |! |! |! |! |! |! |! |! |!
the client's teaching plan
|! |! |!
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,a. Further evaluation involving surgery may be needed
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b. A pelvic exam is also needed before cancer is ruled out
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c. Pap smear evaluation should be continued every six month
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d. One additional negative pap smear in six months is needed.:
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Further evalu- ation involving surgery may be needed
|! |! |! |! |! |! |!
Rationale: An abdominal mass in a client with a family history for
|! |! |! |! |! |! |! |! |! |! |! |!
ovarian cancer should be evaluated carefully
|! |! |! |! |!
3.A client who recently underwent a tracheostomy is being
|! |! |! |! |! |! |! |! |!
prepared for discharge to home. Which instructions is most
|! |! |! |! |! |! |! |! |!
important for the nurse to include in the discharge plan?
|! |! |! |! |! |! |! |! |!
a. Explain how to use communication tools.
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b. Teach tracheal suctioning techniques
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c. Encourage self-care and independence. |! |! |!
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, d. Demonstrate how to clean tracheostomy site.: Teach tracheal
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suctioning
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146
|! |! |! |! |! |! |!
PRIMARY COMPREHENSIVE EXAM |! |! |!
WITH ACCURATYE DETAILED |! |! |!
ANSWERS
1.The nurse observes an unlicensed assistive personnel (UAP)
|! |! |! |! |! |! |! |!
positioning a newly admitted client who has a seizure disorder. The
|! |! |! |! |! |! |! |! |! |! |!
client is supine and the UAP is placing soft pillows along the side
|! |! |! |! |! |! |! |! |! |! |! |! |!
rails. What action should the nurse implement?
|! |! |! |! |! |!
a. Ensure that the UAP has placed the pillows effectively to protect
|! |! |! |! |! |! |! |! |! |! |!
the client. |!
b. Instruct the UAP to obtain soft blankets to secure to the side
|! |! |! |! |! |! |! |! |! |! |! |!
rails instead of pillows.
|! |! |!
c. Assume responsibility for placing the pillows while the UAP
|! |! |! |! |! |! |! |! |!
completes another task. |! |!
1/
146
,d. Ask the UAP to use some of the pillows to prop the client in a
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
side lying position.: Instruct the UAP to obtain soft blankets to
|! |! |! |! |! |! |! |! |! |! |!
secure to the side rails instead of pillows
|! |! |! |! |! |! |!
Rationale: The nurse should instruct the UAP to pad the side rails
|! |! |! |! |! |! |! |! |! |! |! |!
with soft blankest because the use of pillows could result in
|! |! |! |! |! |! |! |! |! |! |!
suffocation and would need to be removed at the onset of the |! |! |! |! |! |! |! |! |! |! |! |!
seizure. The nurse can delegate paddling the side rails to the
|! |! |! |! |! |! |! |! |! |! |!
UAP
2.A 60-year-old female client with a positive family history of
|! |! |! |! |! |! |! |! |! |!
ovarian cancer has developed an abdominal mass and is being
|! |! |! |! |! |! |! |! |! |!
evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear
|! |! |! |! |! |! |! |!
|! results are negative. What information should the nurse include in
|! |! |! |! |! |! |! |! |! |!
the client's teaching plan
|! |! |!
2/
146
,a. Further evaluation involving surgery may be needed
|! |! |! |! |! |!
b. A pelvic exam is also needed before cancer is ruled out
|! |! |! |! |! |! |! |! |! |!
c. Pap smear evaluation should be continued every six month
|! |! |! |! |! |! |! |!
d. One additional negative pap smear in six months is needed.:
|! |! |! |! |! |! |! |! |! |!
Further evalu- ation involving surgery may be needed
|! |! |! |! |! |! |!
Rationale: An abdominal mass in a client with a family history for
|! |! |! |! |! |! |! |! |! |! |! |!
ovarian cancer should be evaluated carefully
|! |! |! |! |!
3.A client who recently underwent a tracheostomy is being
|! |! |! |! |! |! |! |! |!
prepared for discharge to home. Which instructions is most
|! |! |! |! |! |! |! |! |!
important for the nurse to include in the discharge plan?
|! |! |! |! |! |! |! |! |!
a. Explain how to use communication tools.
|! |! |! |! |!
b. Teach tracheal suctioning techniques
|! |! |!
c. Encourage self-care and independence. |! |! |!
3/
146
, d. Demonstrate how to clean tracheostomy site.: Teach tracheal
|! |! |! |! |! |! |! |!
suctioning
4/
146
