HESI 799 RN Exit Exam with |! |! |! |! |! |!
precise detailed solutions |! |!
A male client is admitted for the removal of an internal fixation that was
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
inserted for the fracture ankle. During the admission history, he tells the
|! |! |! |! |! |! |! |! |! |! |! |!
nurse he recently received vancomycin (vancomycin) for a methicillin-
|! |! |! |! |! |! |! |!
resistant Staphylococcus aureus (MRSA) wound infection. Which action
|! |! |! |! |! |! |! |!
should the nurse take? (Select all that apply.)
|! |! |! |! |! |! |!
a. Collect multiple site screening culture for MRSA
|! |! |! |! |! |! |!
b. Call healthcare provider for a prescription for linezolid (Zyrovix)
|! |! |! |! |! |! |! |! |!
c. Place the client on contact transmission precautions
|! |! |! |! |! |! |!
d. Obtain sputum specimen for culture and sensitivity
|! |! |! |! |! |! |!
e. Continue to monitor for client sign of infection. - Correct answer ✔a.
|! |! |! |! |! |! |! |! |! |! |! |! |!
Collect multiple site screening culture for MRSA
|! |! |! |! |! |!
c. Place the client on contact transmission precautions
|! |! |! |! |! |! |!
e. Continue to monitor for client sign of infection.
|! |! |! |! |! |! |! |!
Rationale: Until multi-site screening cultures come back negative (A), the
|! |! |! |! |! |! |! |! |! |!
client should be maintained on contact isolation(C) to minimize the risk for
|! |! |! |! |! |! |! |! |! |! |! |!
nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infecting, is |! |! |! |! |! |! |! |! |!
not indicated, unless the client has an active skin structure infection cause
|! |! |! |! |! |! |! |! |! |! |! |!
by MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus
|! |! |! |! |! |! |! |! |!
aureus. A sputum culture is not indicated D) based on the client's history is
|! |! |! |! |! |! |! |! |! |! |! |! |!
a wound infection.
|! |! |!
,A vacuum-assistive closure (VAC) device is being use to provide wound
|! |! |! |! |! |! |! |! |! |! |!
care for a client who has stage III pressure ulcer on a below-the- knee
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
(BKA) residual limb. Which intervention should the nurse implement to
|! |! |! |! |! |! |! |! |! |!
ensure maximum effectiveness of the device?
|! |! |! |! |!
a. Empty the device every 8 hours and change the dressing daily ensure
|! |! |! |! |! |! |! |! |! |! |! |! |!
sterility
b. Extended the transparent film dressing only to edge of wound to prevent
|! |! |! |! |! |! |! |! |! |! |! |!
tension.
|!
c. Ensure the transparent dressing has no tears that might create vacuum
|! |! |! |! |! |! |! |! |! |! |! |!
leaks
d. Use an adhesive remover when changing the dressing to promote
|! |! |! |! |! |! |! |! |! |! |!
comfort. - Correct answer ✔Ensure the transparent dressing has no tears
|! |! |! |! |! |! |! |! |! |! |!
that might create vacuum leak
|! |! |! |!
Rationale: The nurse should ensure that the VAC transparent film is intact,|! |! |! |! |! |! |! |! |! |! |! |!
without tears or loose edges C) because a break in the seal resulting in
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
drying the wound and decreasing the vacuum. The vacuum-assisted
|! |! |! |! |! |! |! |! |!
closure (VAC) device uses an open sponge in the wound bed, sealed with
|! |! |! |! |! |! |! |! |! |! |! |! |!
a transparent film dressing and tube extrudes to a suction device that
|! |! |! |! |! |! |! |! |! |! |! |!
exert negative pressure to remove excess wound fluid, reduce the
|! |! |! |! |! |! |! |! |! |!
bacterial count and stimulate granulation. The VAC is changed every other
|! |! |! |! |! |! |! |! |! |!
day or third day, not (A) depending on the stage of wound healing and
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
emptied when full or weekly. The transparent wound dressing should
|! |! |! |! |! |! |! |! |! |!
extend 3 to 5 cm beyond the wound edges, not (B) to ensure and airtight
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
seal. Adhesive removers leave a reduce that binder transparent film
|! |! |! |! |! |! |! |! |! |!
adherence (D) |!
The nurse is developing the plan of care for a client with pneumonia and
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
includes the nursing diagnosis of "Ineffective airway clearance related to
|! |! |! |! |! |! |! |! |! |!
,thick pulmonary secretions." Which intervention is most important for the
|! |! |! |! |! |! |! |! |! |!
nurse to include in the client's plan of care?
|! |! |! |! |! |! |! |!
a. Increase fluid intake to 3,000 ml/daily
|! |! |! |! |! |!
b. Administer O2 at 5L/mint per nasal cannula
|! |! |! |! |! |! |!
c. Maintain the client in a semi Fowler's position
|! |! |! |! |! |! |! |!
d. Provide frequent rest period. - Correct answer ✔Increase fluid intake to
|! |! |! |! |! |! |! |! |! |! |! |!
3,000 ml/daily |!
Rationale: The plan of care should include an increase in fluid intake (A) to
|! |! |! |! |! |! |! |! |! |! |! |! |!
liquefy and thin secretions for easier removal of thick pulmonary secretion
|! |! |! |! |! |! |! |! |! |! |! |!
which facilitates airway clearance. (B) should be implemented for signs of
|! |! |! |! |! |! |! |! |! |! |!
hypoxia (C) implemented to facilitate lung expansion, and (D) implemented
|! |! |! |! |! |! |! |! |!
for activity intolerance, but these interventions do not have the priority of
|! |! |! |! |! |! |! |! |! |! |! |! |!
(A)
The nurse plans to collect a 24- hour urine specimen for a creatinine
|! |! |! |! |! |! |! |! |! |! |! |! |!
clearance test. Which instruction should the nurse provide to the adult
|! |! |! |! |! |! |! |! |! |! |!
male client? |!
a. Clearance around the meatus, discard first portion of voiding, and
|! |! |! |! |! |! |! |! |! |! |!
collect the rest in a sterile bottle|! |! |! |! |! |!
b. Urinate at specific time, discard the urine, and collect all subsequent
|! |! |! |! |! |! |! |! |! |! |! |!
urine during the next 24 hours.
|! |! |! |! |!
c. For the next 24 hours, notify the nurse when the bladder is full, and the
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
nurse will collect catheterized specimens.
|! |! |! |!
d. Urinate immediately into a urinal, and the lab will collect specimen every
|! |! |! |! |! |! |! |! |! |! |! |!
6 hours, for the next 24 hours. - Correct answer ✔Urinate at specific time,
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
, discard the urine, and collect all subsequent urine during the next 24
|! |! |! |! |! |! |! |! |! |! |! |!
hours.
Rationale: Urinate at specific time, discard the urine, and collect all
|! |! |! |! |! |! |! |! |! |! |!
subsequent urine during the next 24 hours is the correct procedure for
|! |! |! |! |! |! |! |! |! |! |! |!
collecting 24-hour urine specimen. Discarding even one voided specimen
|! |! |! |! |! |! |! |! |!
invalidate the test. |! |!
The nurse is preparing to administer a histamine 2-receptor antagonist to
|! |! |! |! |! |! |! |! |! |! |!
a client with peptic ulcer disease. What is the primary purpose of this drug
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
classification?
a. Neutralize hydrochloric (HCI) acid in the stomach
|! |! |! |! |! |! |!
b. Decreases the amount of HCL secretion by the parietal cells in the
|! |! |! |! |! |! |! |! |! |! |! |! |!
stomach
c. Inhibit action of acetylcholine by blocking parasympathetic nerve
|! |! |! |! |! |! |! |! |!
endings.
d. Destroys microorganisms causing stomach inflammation. - Correct
|! |! |! |! |! |! |! |!
answer ✔Decreases the amount of HCL secretion by the parietal cells in
|! |! |! |! |! |! |! |! |! |! |! |!
the stomach|!
Rationale: B correctly describe the action of histamine 2 receptor
|! |! |! |! |! |! |! |! |! |!
antagonist in helping to prevent peptic ulcer disease.
|! |! |! |! |! |! |!
The healthcare provider prescribes acarbose (Precose), an alpha-
|! |! |! |! |! |! |!
glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which
|! |! |! |! |! |! |! |! |! |! |!
information provides the best indicator of the drug's effectiveness?
|! |! |! |! |! |! |! |!
precise detailed solutions |! |!
A male client is admitted for the removal of an internal fixation that was
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
inserted for the fracture ankle. During the admission history, he tells the
|! |! |! |! |! |! |! |! |! |! |! |!
nurse he recently received vancomycin (vancomycin) for a methicillin-
|! |! |! |! |! |! |! |!
resistant Staphylococcus aureus (MRSA) wound infection. Which action
|! |! |! |! |! |! |! |!
should the nurse take? (Select all that apply.)
|! |! |! |! |! |! |!
a. Collect multiple site screening culture for MRSA
|! |! |! |! |! |! |!
b. Call healthcare provider for a prescription for linezolid (Zyrovix)
|! |! |! |! |! |! |! |! |!
c. Place the client on contact transmission precautions
|! |! |! |! |! |! |!
d. Obtain sputum specimen for culture and sensitivity
|! |! |! |! |! |! |!
e. Continue to monitor for client sign of infection. - Correct answer ✔a.
|! |! |! |! |! |! |! |! |! |! |! |! |!
Collect multiple site screening culture for MRSA
|! |! |! |! |! |!
c. Place the client on contact transmission precautions
|! |! |! |! |! |! |!
e. Continue to monitor for client sign of infection.
|! |! |! |! |! |! |! |!
Rationale: Until multi-site screening cultures come back negative (A), the
|! |! |! |! |! |! |! |! |! |!
client should be maintained on contact isolation(C) to minimize the risk for
|! |! |! |! |! |! |! |! |! |! |! |!
nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infecting, is |! |! |! |! |! |! |! |! |!
not indicated, unless the client has an active skin structure infection cause
|! |! |! |! |! |! |! |! |! |! |! |!
by MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus
|! |! |! |! |! |! |! |! |!
aureus. A sputum culture is not indicated D) based on the client's history is
|! |! |! |! |! |! |! |! |! |! |! |! |!
a wound infection.
|! |! |!
,A vacuum-assistive closure (VAC) device is being use to provide wound
|! |! |! |! |! |! |! |! |! |! |!
care for a client who has stage III pressure ulcer on a below-the- knee
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
(BKA) residual limb. Which intervention should the nurse implement to
|! |! |! |! |! |! |! |! |! |!
ensure maximum effectiveness of the device?
|! |! |! |! |!
a. Empty the device every 8 hours and change the dressing daily ensure
|! |! |! |! |! |! |! |! |! |! |! |! |!
sterility
b. Extended the transparent film dressing only to edge of wound to prevent
|! |! |! |! |! |! |! |! |! |! |! |!
tension.
|!
c. Ensure the transparent dressing has no tears that might create vacuum
|! |! |! |! |! |! |! |! |! |! |! |!
leaks
d. Use an adhesive remover when changing the dressing to promote
|! |! |! |! |! |! |! |! |! |! |!
comfort. - Correct answer ✔Ensure the transparent dressing has no tears
|! |! |! |! |! |! |! |! |! |! |!
that might create vacuum leak
|! |! |! |!
Rationale: The nurse should ensure that the VAC transparent film is intact,|! |! |! |! |! |! |! |! |! |! |! |!
without tears or loose edges C) because a break in the seal resulting in
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
drying the wound and decreasing the vacuum. The vacuum-assisted
|! |! |! |! |! |! |! |! |!
closure (VAC) device uses an open sponge in the wound bed, sealed with
|! |! |! |! |! |! |! |! |! |! |! |! |!
a transparent film dressing and tube extrudes to a suction device that
|! |! |! |! |! |! |! |! |! |! |! |!
exert negative pressure to remove excess wound fluid, reduce the
|! |! |! |! |! |! |! |! |! |!
bacterial count and stimulate granulation. The VAC is changed every other
|! |! |! |! |! |! |! |! |! |!
day or third day, not (A) depending on the stage of wound healing and
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
emptied when full or weekly. The transparent wound dressing should
|! |! |! |! |! |! |! |! |! |!
extend 3 to 5 cm beyond the wound edges, not (B) to ensure and airtight
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
seal. Adhesive removers leave a reduce that binder transparent film
|! |! |! |! |! |! |! |! |! |!
adherence (D) |!
The nurse is developing the plan of care for a client with pneumonia and
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
includes the nursing diagnosis of "Ineffective airway clearance related to
|! |! |! |! |! |! |! |! |! |!
,thick pulmonary secretions." Which intervention is most important for the
|! |! |! |! |! |! |! |! |! |!
nurse to include in the client's plan of care?
|! |! |! |! |! |! |! |!
a. Increase fluid intake to 3,000 ml/daily
|! |! |! |! |! |!
b. Administer O2 at 5L/mint per nasal cannula
|! |! |! |! |! |! |!
c. Maintain the client in a semi Fowler's position
|! |! |! |! |! |! |! |!
d. Provide frequent rest period. - Correct answer ✔Increase fluid intake to
|! |! |! |! |! |! |! |! |! |! |! |!
3,000 ml/daily |!
Rationale: The plan of care should include an increase in fluid intake (A) to
|! |! |! |! |! |! |! |! |! |! |! |! |!
liquefy and thin secretions for easier removal of thick pulmonary secretion
|! |! |! |! |! |! |! |! |! |! |! |!
which facilitates airway clearance. (B) should be implemented for signs of
|! |! |! |! |! |! |! |! |! |! |!
hypoxia (C) implemented to facilitate lung expansion, and (D) implemented
|! |! |! |! |! |! |! |! |!
for activity intolerance, but these interventions do not have the priority of
|! |! |! |! |! |! |! |! |! |! |! |! |!
(A)
The nurse plans to collect a 24- hour urine specimen for a creatinine
|! |! |! |! |! |! |! |! |! |! |! |! |!
clearance test. Which instruction should the nurse provide to the adult
|! |! |! |! |! |! |! |! |! |! |!
male client? |!
a. Clearance around the meatus, discard first portion of voiding, and
|! |! |! |! |! |! |! |! |! |! |!
collect the rest in a sterile bottle|! |! |! |! |! |!
b. Urinate at specific time, discard the urine, and collect all subsequent
|! |! |! |! |! |! |! |! |! |! |! |!
urine during the next 24 hours.
|! |! |! |! |!
c. For the next 24 hours, notify the nurse when the bladder is full, and the
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
nurse will collect catheterized specimens.
|! |! |! |!
d. Urinate immediately into a urinal, and the lab will collect specimen every
|! |! |! |! |! |! |! |! |! |! |! |!
6 hours, for the next 24 hours. - Correct answer ✔Urinate at specific time,
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
, discard the urine, and collect all subsequent urine during the next 24
|! |! |! |! |! |! |! |! |! |! |! |!
hours.
Rationale: Urinate at specific time, discard the urine, and collect all
|! |! |! |! |! |! |! |! |! |! |!
subsequent urine during the next 24 hours is the correct procedure for
|! |! |! |! |! |! |! |! |! |! |! |!
collecting 24-hour urine specimen. Discarding even one voided specimen
|! |! |! |! |! |! |! |! |!
invalidate the test. |! |!
The nurse is preparing to administer a histamine 2-receptor antagonist to
|! |! |! |! |! |! |! |! |! |! |!
a client with peptic ulcer disease. What is the primary purpose of this drug
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
classification?
a. Neutralize hydrochloric (HCI) acid in the stomach
|! |! |! |! |! |! |!
b. Decreases the amount of HCL secretion by the parietal cells in the
|! |! |! |! |! |! |! |! |! |! |! |! |!
stomach
c. Inhibit action of acetylcholine by blocking parasympathetic nerve
|! |! |! |! |! |! |! |! |!
endings.
d. Destroys microorganisms causing stomach inflammation. - Correct
|! |! |! |! |! |! |! |!
answer ✔Decreases the amount of HCL secretion by the parietal cells in
|! |! |! |! |! |! |! |! |! |! |! |!
the stomach|!
Rationale: B correctly describe the action of histamine 2 receptor
|! |! |! |! |! |! |! |! |! |!
antagonist in helping to prevent peptic ulcer disease.
|! |! |! |! |! |! |!
The healthcare provider prescribes acarbose (Precose), an alpha-
|! |! |! |! |! |! |!
glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which
|! |! |! |! |! |! |! |! |! |! |!
information provides the best indicator of the drug's effectiveness?
|! |! |! |! |! |! |! |!
