HESI 799 RN Exit Exam with |! |! |! |! |! |!
accurate detailed answers |! |!
An adult client is exhibit the manic stage of bipolar disorder is admitted to
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the psychiatric unit. The client has lost 10 pounds in the last two weeks
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and has no bathed in a week "I'm trying to start a new business and "I'm
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too busy to eat". The client is oriented to time, place, person but not
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situation. Which nursing problem has the greatest priority?
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a. Hygiene-self-care deficit
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b. Imbalance nutrition
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c. Disturbed sleep pattern
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d. Self-neglect - Correct answer ✔Imbalance nutrition
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Rationale: The client's nutritional status has the highest priority at this
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time, and finger foods are often provided, so the client who is on the
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maniac phase of bipolar disease can receive adequate nutrition. Other
|! |! |! |! |! |! |! |! |! |!
options are nursing problems that should also be addresses with the
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client's plan of care, but at this stage in the client's treatment, adequate
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nutrition is a priority |! |! |!
A client who had a percutaneous transluminal coronary angioplasty
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(PTCA) two weeks ago returns to the clinic for a follow up visit. The client
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has a postoperative ejection fraction ejection fraction of 30%. Today the
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client has lungs which are clear, +1 pedal edema, and a 5pound weight
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gain. Which intervention the nurse implement?
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,a. Arrange transport for admission to the hospital.
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b. Insert saline lock for IV diuretic therapy.
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c. Assess compliance with routine prescriptions.
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d. Instruct the client to monitor daily caloric intake. - Correct answer
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✔Assess compliance with routine prescriptions. |! |! |! |!
Rationale: Fluid retention may be a sign that the client is not taking the
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
medication as prescribed or that the prescriptions may need adjustment to
|! |! |! |! |! |! |! |! |! |! |!
manage cardiac function post-PTCA (normal ejection fraction range is 50
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to 75%)
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The nurse is assessing a client's nailbeds. Witch appearance indicates
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further follow-up is needed for problems associated with chronic hypoxia?
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Clubbing FLIP for photo!!! - Correct answer ✔clubbing
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The RN is assigned to care for four surgical clients. After receiving report,
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which client should the nurse see first? The client who is:
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a. Two days postoperative bladder surgery with continuous bladder
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irrigation infusing. |!
b. One day postoperative laparoscopic cholecystectomy requesting pain
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medication.
c. Three days postoperative colon resection receiving transfusion of
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packed RBCs. |!
d. Preoperative, in buck's traction, and scheduled for hip arthroplasty
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within the next 12 hours. - Correct answer ✔Three days postoperative
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colon resection receiving transfusion of packed RBCs.
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,The nurse is preparing an older client for discharge following cataract
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extraction. Which instruction should be include in the discharge teaching?
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a. Do not read without direct lighting for 6 weeks.
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b. Avoid straining at stool, bending, or lifting heavy objects.
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c. Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic
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ointment.
d. Limit exposure to sunlight during the first 2 weeks when the cornea is
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
healing. - Correct answer ✔Avoid straining at stool, bending, or lifting
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heavy objects |!
Rationale: after cataract surgery, the client should avoid activities which
|! |! |! |! |! |! |! |! |! |!
increase pressure and place strain on the suture line.
|! |! |! |! |! |! |! |!
The healthcare provider prescribes potassium chloride 25 mEq in 500 ml
|! |! |! |! |! |! |! |! |! |! |!
D_5W to infuse over 6 hours. The available 20 ml vial of potassium
|! |! |! |! |! |! |! |! |! |! |! |! |!
chloride is labeled, "10 mEq/5ml." how many ml of potassium chloride
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should the nurse add the IV fluid? (Enter numeric value only. If is rounding
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
is required, round to the nearest tenth.)
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12.5 - Correct answer ✔12.5
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Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml
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At 40 week gestation, a laboring client who is lying is a supine position
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tells the nurse that she has finally found a comfortable position. What
|! |! |! |! |! |! |! |! |! |! |! |!
action should the nurse take?
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, a. Encourage the client to turn on her left side.
|! |! |! |! |! |! |! |! |!
b. Place a pillow under the client's head and knees.
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c. Explain to the client that her position is not safe.
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d. Place a wedge under the client's right hip. - Correct answer ✔Place a
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wedge under the client's right hip |! |! |! |! |!
Rationale: Hypotension from pressure on the vena cava is a risk for the |! |! |! |! |! |! |! |! |! |! |! |! |!
full-term client. Placing a wedge under the right hip will relieve pressure on
|! |! |! |! |! |! |! |! |! |! |! |!
the vena cava. Other options will either not relieve pressure on the vena
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
cava or would not allow the client the remaining her position of choice.
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The nurse is preparing a 4-day-old I infant with a serum bilirubin level of
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching
|! |! |! |! |! |! |! |! |! |! |!
the parents about home phototherapy, which instruction should the nurse
|! |! |! |! |! |! |! |! |! |!
include in the discharge teaching plan? |! |! |! |! |!
a. Reposition the infant every 2 hours.
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b. Perform diaper changes under the light.
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c. Feed the infant every 4 hours.
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d. Cover with a receiving blanket. - Correct answer ✔Reposition the infant
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every 2 hours. |! |!
Rational: An infant, who is receiving phototherapy for hyperbilirubinemia,
|! |! |! |! |! |! |! |! |!
should be repositioned every two hours. The position changes ensure that
|! |! |! |! |! |! |! |! |! |! |!
the phototherapy lights reach all of the body surface areas. Bathing,
|! |! |! |! |! |! |! |! |! |! |!
feedings, and diaper changes are ways for the parents to bond with the
|! |! |! |! |! |! |! |! |! |! |! |! |!
infant and can occur away from the treatment. Feedings need to occur
|! |! |! |! |! |! |! |! |! |! |! |!
more frequently than every 4 hours to prevent dehydration. The infant
|! |! |! |! |! |! |! |! |! |! |!
should wear only a diaper so that the skin is exposed to the phototherapy.
|! |! |! |! |! |! |! |! |! |! |! |! |!
accurate detailed answers |! |!
An adult client is exhibit the manic stage of bipolar disorder is admitted to
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
the psychiatric unit. The client has lost 10 pounds in the last two weeks
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
and has no bathed in a week "I'm trying to start a new business and "I'm
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
too busy to eat". The client is oriented to time, place, person but not
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
situation. Which nursing problem has the greatest priority?
|! |! |! |! |! |! |!
a. Hygiene-self-care deficit
|! |!
b. Imbalance nutrition
|! |!
c. Disturbed sleep pattern
|! |! |!
d. Self-neglect - Correct answer ✔Imbalance nutrition
|! |! |! |! |! |!
Rationale: The client's nutritional status has the highest priority at this
|! |! |! |! |! |! |! |! |! |! |!
time, and finger foods are often provided, so the client who is on the
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
maniac phase of bipolar disease can receive adequate nutrition. Other
|! |! |! |! |! |! |! |! |! |!
options are nursing problems that should also be addresses with the
|! |! |! |! |! |! |! |! |! |! |!
client's plan of care, but at this stage in the client's treatment, adequate
|! |! |! |! |! |! |! |! |! |! |! |! |!
nutrition is a priority |! |! |!
A client who had a percutaneous transluminal coronary angioplasty
|! |! |! |! |! |! |! |! |!
(PTCA) two weeks ago returns to the clinic for a follow up visit. The client
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
has a postoperative ejection fraction ejection fraction of 30%. Today the
|! |! |! |! |! |! |! |! |! |! |!
client has lungs which are clear, +1 pedal edema, and a 5pound weight
|! |! |! |! |! |! |! |! |! |! |! |! |!
gain. Which intervention the nurse implement?
|! |! |! |! |!
,a. Arrange transport for admission to the hospital.
|! |! |! |! |! |! |!
b. Insert saline lock for IV diuretic therapy.
|! |! |! |! |! |! |!
c. Assess compliance with routine prescriptions.
|! |! |! |! |!
d. Instruct the client to monitor daily caloric intake. - Correct answer
|! |! |! |! |! |! |! |! |! |! |! |!
✔Assess compliance with routine prescriptions. |! |! |! |!
Rationale: Fluid retention may be a sign that the client is not taking the
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
medication as prescribed or that the prescriptions may need adjustment to
|! |! |! |! |! |! |! |! |! |! |!
manage cardiac function post-PTCA (normal ejection fraction range is 50
|! |! |! |! |! |! |! |! |! |!
to 75%)
|!
The nurse is assessing a client's nailbeds. Witch appearance indicates
|! |! |! |! |! |! |! |! |! |!
further follow-up is needed for problems associated with chronic hypoxia?
|! |! |! |! |! |! |! |! |!
Clubbing FLIP for photo!!! - Correct answer ✔clubbing
|! |! |! |! |! |! |!
The RN is assigned to care for four surgical clients. After receiving report,
|! |! |! |! |! |! |! |! |! |! |! |! |!
which client should the nurse see first? The client who is:
|! |! |! |! |! |! |! |! |! |!
a. Two days postoperative bladder surgery with continuous bladder
|! |! |! |! |! |! |! |! |!
irrigation infusing. |!
b. One day postoperative laparoscopic cholecystectomy requesting pain
|! |! |! |! |! |! |! |!
medication.
c. Three days postoperative colon resection receiving transfusion of
|! |! |! |! |! |! |! |! |!
packed RBCs. |!
d. Preoperative, in buck's traction, and scheduled for hip arthroplasty
|! |! |! |! |! |! |! |! |! |!
within the next 12 hours. - Correct answer ✔Three days postoperative
|! |! |! |! |! |! |! |! |! |! |!
colon resection receiving transfusion of packed RBCs.
|! |! |! |! |! |!
,The nurse is preparing an older client for discharge following cataract
|! |! |! |! |! |! |! |! |! |! |!
extraction. Which instruction should be include in the discharge teaching?
|! |! |! |! |! |! |! |! |!
a. Do not read without direct lighting for 6 weeks.
|! |! |! |! |! |! |! |! |!
b. Avoid straining at stool, bending, or lifting heavy objects.
|! |! |! |! |! |! |! |! |!
c. Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic
|! |! |! |! |! |! |! |! |! |!
ointment.
d. Limit exposure to sunlight during the first 2 weeks when the cornea is
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
healing. - Correct answer ✔Avoid straining at stool, bending, or lifting
|! |! |! |! |! |! |! |! |! |! |!
heavy objects |!
Rationale: after cataract surgery, the client should avoid activities which
|! |! |! |! |! |! |! |! |! |!
increase pressure and place strain on the suture line.
|! |! |! |! |! |! |! |!
The healthcare provider prescribes potassium chloride 25 mEq in 500 ml
|! |! |! |! |! |! |! |! |! |! |!
D_5W to infuse over 6 hours. The available 20 ml vial of potassium
|! |! |! |! |! |! |! |! |! |! |! |! |!
chloride is labeled, "10 mEq/5ml." how many ml of potassium chloride
|! |! |! |! |! |! |! |! |! |! |!
should the nurse add the IV fluid? (Enter numeric value only. If is rounding
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
is required, round to the nearest tenth.)
|! |! |! |! |! |!
12.5 - Correct answer ✔12.5
|! |! |! |!
Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
At 40 week gestation, a laboring client who is lying is a supine position
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
tells the nurse that she has finally found a comfortable position. What
|! |! |! |! |! |! |! |! |! |! |! |!
action should the nurse take?
|! |! |! |!
, a. Encourage the client to turn on her left side.
|! |! |! |! |! |! |! |! |!
b. Place a pillow under the client's head and knees.
|! |! |! |! |! |! |! |! |!
c. Explain to the client that her position is not safe.
|! |! |! |! |! |! |! |! |! |!
d. Place a wedge under the client's right hip. - Correct answer ✔Place a
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
wedge under the client's right hip |! |! |! |! |!
Rationale: Hypotension from pressure on the vena cava is a risk for the |! |! |! |! |! |! |! |! |! |! |! |! |!
full-term client. Placing a wedge under the right hip will relieve pressure on
|! |! |! |! |! |! |! |! |! |! |! |!
the vena cava. Other options will either not relieve pressure on the vena
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
cava or would not allow the client the remaining her position of choice.
|! |! |! |! |! |! |! |! |! |! |! |!
The nurse is preparing a 4-day-old I infant with a serum bilirubin level of
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching
|! |! |! |! |! |! |! |! |! |! |!
the parents about home phototherapy, which instruction should the nurse
|! |! |! |! |! |! |! |! |! |!
include in the discharge teaching plan? |! |! |! |! |!
a. Reposition the infant every 2 hours.
|! |! |! |! |! |!
b. Perform diaper changes under the light.
|! |! |! |! |! |!
c. Feed the infant every 4 hours.
|! |! |! |! |! |!
d. Cover with a receiving blanket. - Correct answer ✔Reposition the infant
|! |! |! |! |! |! |! |! |! |! |! |!
every 2 hours. |! |!
Rational: An infant, who is receiving phototherapy for hyperbilirubinemia,
|! |! |! |! |! |! |! |! |!
should be repositioned every two hours. The position changes ensure that
|! |! |! |! |! |! |! |! |! |! |!
the phototherapy lights reach all of the body surface areas. Bathing,
|! |! |! |! |! |! |! |! |! |! |!
feedings, and diaper changes are ways for the parents to bond with the
|! |! |! |! |! |! |! |! |! |! |! |! |!
infant and can occur away from the treatment. Feedings need to occur
|! |! |! |! |! |! |! |! |! |! |! |!
more frequently than every 4 hours to prevent dehydration. The infant
|! |! |! |! |! |! |! |! |! |! |!
should wear only a diaper so that the skin is exposed to the phototherapy.
|! |! |! |! |! |! |! |! |! |! |! |! |!
