HESI RN EXIT EXAM LEGACY
V2 QUESTIONS & CORRECT
ANSWERS (100% COMPLETE)
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
,As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in
the treatment room, he cries continuously. What intervention should the nurse
implement?
Take the child back to his room.
Recruit others to restrain the child.
Ask the mother to be present to soothe the child.
Show the child how to manipulate the equipment.
Ask the mother to be present to soothe the child.
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities.
The mother's assistance (C) can provide a stabilizing presence to help soothe the
preschooler, who may perceive the invasive procedure as mutilating. To preserve
the child's sense of security associated with the hospital room, it is best to perform
difficult or painful procedures in another area (A). (B) may be necessary to prevent
injury if the child is unable to cooperate with the mother's coaxing. (D) is best done
before going to the treatment room when the child feels less threatened.
In evaluating client care, which action should the nurse take first?
Determine if the expected outcomes of care were achieved.
Review the rationales used as the basis of nursing actions.
Document the care plan goals that were successfully met.
Prioritize interventions to be added to the client's plan of care.
Submit
Determine if the expected outcomes of care were achieved.
Rationale
In evaluating care, the nurse should first determine if the expected outcomes of the
plan of care were achieved.
,
How should the nurse handle linens that are soiled with incontinent feces?
Put the soiled linens in an isolation bag, then place it in the dirty linen hamper.
,Place an isolation hamper in the client's room and discard the linens in it.
Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.
Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.
Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.
Rationale
The nurse should be careful to keep the soiled linens from contaminating the fresh
linens, and should handle the soiled linens like any other dirty linen (C). (A, B, and
D) are not indicated.
,
What action should the nurse implement when adding sterile liquids to a sterile
field?
Use an outdated sterile liquid if the bottle is sealed and has not been opened.
Consider the sterile field contaminated if it becomes wet during the procedure.
Remove the container cap and lay it with the inside facing down on the sterile field.
Hold the container high and pour the solution into a receptacle at the back of the sterile
field.
Consider the sterile field contaminated if it becomes wet during the procedure.
Rationale
Wet or damp areas on a sterile field allow organisms to “wick” from the table
surface and permeate into the sterile area, so the field is considered contaminated
if it becomes wet (B). Outdated liquids may be contaminated and should be
discarded, not used (A). The container's cap should be removed, placed facing up,
and off the sterile field, not (C). To prevent contamination of the sterile field, liquids
should be held close (6 inches) to the receptacle when pouring to prevent
splashing, and the receptacle should be placed near the front edge to avoid
reaching over or across the sterile field (D).
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance
related to lack of motivation" for a client with Type 2 diabetes. Which finding
supports this nursing diagnosis?
Does not check capillary blood glucose as directed.
, Occasionally forgets to take daily prescribed medication.
Cannot identify signs or symptoms of high and low blood glucose.
Eats anything and does not think diet makes a difference in health.
Eats anything and does not think diet makes a difference in health.
Rationale
The nursing diagnosis of ineffective health maintenance refers to an inability to
identify, manage, and/or seek out help to maintain health, and is best exemplified
in the client belief or understanding about diet and health maintainance (D). (A)
indicates noncompliance with an action to be done in the management of diabetes.
(B) represents inattentiveness. (C) reflects knowledge deficit.
What intervention should the nurse include in the plan of care for a client who is
being treated with an Unna’s paste boot for leg ulcers due to chronic venous
insufficiency?
Check capillary refill of toes on lower extremity with Unna's paste boot.
Apply dressing to wound area before applying the Unna's paste boot.
Wrap the leg from the knee down towards the foot.
Remove the Unna's paste boot q8h to assess wound healing.
Check capillary refill of toes on lower extremity with Unna's paste boot.
Rationale
The Unna’s paste boot becomes rigid after it dries, so it is important to check
distally for adequate circulation (A). Kerlix is often wrapped around the outside of
the boot and an ace bandage may be used to cover both, but no bandage should be
put under it (B). The Unna’s paste boot should be applied from the foot and
wrapped towards the knee (C). The Unna’s paste boot acts as a sterile dressing,
and should not be removed q8h. Weekly removal is reasonable (D).
,
The nurse is digitally removing a fecal impaction for a client. The nurse should stop
the procedure and take corrective action if which client reaction is noted?
Temperature increases from 98.8 to 99.0 F.
Pulse rate decreases from 78 to 52 beats/min.
V2 QUESTIONS & CORRECT
ANSWERS (100% COMPLETE)
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
,As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in
the treatment room, he cries continuously. What intervention should the nurse
implement?
Take the child back to his room.
Recruit others to restrain the child.
Ask the mother to be present to soothe the child.
Show the child how to manipulate the equipment.
Ask the mother to be present to soothe the child.
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities.
The mother's assistance (C) can provide a stabilizing presence to help soothe the
preschooler, who may perceive the invasive procedure as mutilating. To preserve
the child's sense of security associated with the hospital room, it is best to perform
difficult or painful procedures in another area (A). (B) may be necessary to prevent
injury if the child is unable to cooperate with the mother's coaxing. (D) is best done
before going to the treatment room when the child feels less threatened.
In evaluating client care, which action should the nurse take first?
Determine if the expected outcomes of care were achieved.
Review the rationales used as the basis of nursing actions.
Document the care plan goals that were successfully met.
Prioritize interventions to be added to the client's plan of care.
Submit
Determine if the expected outcomes of care were achieved.
Rationale
In evaluating care, the nurse should first determine if the expected outcomes of the
plan of care were achieved.
,
How should the nurse handle linens that are soiled with incontinent feces?
Put the soiled linens in an isolation bag, then place it in the dirty linen hamper.
,Place an isolation hamper in the client's room and discard the linens in it.
Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.
Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.
Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.
Rationale
The nurse should be careful to keep the soiled linens from contaminating the fresh
linens, and should handle the soiled linens like any other dirty linen (C). (A, B, and
D) are not indicated.
,
What action should the nurse implement when adding sterile liquids to a sterile
field?
Use an outdated sterile liquid if the bottle is sealed and has not been opened.
Consider the sterile field contaminated if it becomes wet during the procedure.
Remove the container cap and lay it with the inside facing down on the sterile field.
Hold the container high and pour the solution into a receptacle at the back of the sterile
field.
Consider the sterile field contaminated if it becomes wet during the procedure.
Rationale
Wet or damp areas on a sterile field allow organisms to “wick” from the table
surface and permeate into the sterile area, so the field is considered contaminated
if it becomes wet (B). Outdated liquids may be contaminated and should be
discarded, not used (A). The container's cap should be removed, placed facing up,
and off the sterile field, not (C). To prevent contamination of the sterile field, liquids
should be held close (6 inches) to the receptacle when pouring to prevent
splashing, and the receptacle should be placed near the front edge to avoid
reaching over or across the sterile field (D).
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance
related to lack of motivation" for a client with Type 2 diabetes. Which finding
supports this nursing diagnosis?
Does not check capillary blood glucose as directed.
, Occasionally forgets to take daily prescribed medication.
Cannot identify signs or symptoms of high and low blood glucose.
Eats anything and does not think diet makes a difference in health.
Eats anything and does not think diet makes a difference in health.
Rationale
The nursing diagnosis of ineffective health maintenance refers to an inability to
identify, manage, and/or seek out help to maintain health, and is best exemplified
in the client belief or understanding about diet and health maintainance (D). (A)
indicates noncompliance with an action to be done in the management of diabetes.
(B) represents inattentiveness. (C) reflects knowledge deficit.
What intervention should the nurse include in the plan of care for a client who is
being treated with an Unna’s paste boot for leg ulcers due to chronic venous
insufficiency?
Check capillary refill of toes on lower extremity with Unna's paste boot.
Apply dressing to wound area before applying the Unna's paste boot.
Wrap the leg from the knee down towards the foot.
Remove the Unna's paste boot q8h to assess wound healing.
Check capillary refill of toes on lower extremity with Unna's paste boot.
Rationale
The Unna’s paste boot becomes rigid after it dries, so it is important to check
distally for adequate circulation (A). Kerlix is often wrapped around the outside of
the boot and an ace bandage may be used to cover both, but no bandage should be
put under it (B). The Unna’s paste boot should be applied from the foot and
wrapped towards the knee (C). The Unna’s paste boot acts as a sterile dressing,
and should not be removed q8h. Weekly removal is reasonable (D).
,
The nurse is digitally removing a fecal impaction for a client. The nurse should stop
the procedure and take corrective action if which client reaction is noted?
Temperature increases from 98.8 to 99.0 F.
Pulse rate decreases from 78 to 52 beats/min.
