HESI EXIT RN EXAM g g g
(750 QUESTIONS AND ANSWERS, RATIONALE OF EAC
g g g g g g
H ANSWER INCLUDED)
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1. Following discharge teaching, a male client with duodenal ulcer tells t
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he nurse the he will drink plenty of dairy products, such as milk, to hel
g g g g g g g g g g g g g g
p coat and protect his ulcer. What is the best follow-
g g g g g g g g g g
up action by the nurse?
g g g g
a- Remind the client that it is also important to switch to decaffeinated c
g g g g g g g g g g g g
offee and tea. g g
b- Suggest that the client also plan to eat frequent small meals to re
g g g g g g g g g g g g
duce discomfort g
c- Review with the client the need to avoid foods that are rich in m
g g g g g g g g g g g g g
ilk and cream.
g g
d- Reinforce this teaching by asking the client to list a dairy food that he mi
g g g g g g g g g g g g g g
ght select.
g
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and sho
g g g g g g g g g g g g
uld be avoided.
g g
2. A male client with hypertension, who received new antihypertensive p
g g g g g g g g g
rescriptions at his last visit returns to the clinic
g g g g g g g g
, two weeks later to evaluate his blood pressure (BP). His BP is 158/106 a
g g g g g g g g g g g g g
nd he admits that he has not been taking the prescribed medication bec
g g g g g g g g g g g g
ause the drugs make him “feel bad”. In explaining the need for hyperte
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nsion control, the nurse should stress that an elevated BP places the clie
g g g g g g g g g g g g
nt at risk for which pathophysiological condition?
g g g g g g
a- Blindness secondary to cataracts b- g g g g
Acute kidney injury due to glomerular damage c-
g g g g g g g g
gStroke secondary to hemorrhage d- g g g g
gHeart block due to myocardial damage
g g g g g
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
g g g g g g g g g g g
hypertension.
3. The nurse observes an unlicensed assistive personnel (UAP) position
g g g g g g g g
ing a newly admitted client who has a seizure disorder. The client is s
g g g g g g g g g g g g g
upine and the UAP is placing soft pillows along the side rails. What a
g g g g g g g g g g g g g
ction should the nurse implement?
g g g g
a- Ensure that the UAP has placed the pillows effectively to protect the cl
g g g g g g g g g g g g
ient.
b- Instruct the UAP to obtain soft blankets to secure to the side rails
g g g g g g g g g g g g
, instead of pillows. g g
a- Assume responsibility for placing the pillows while the UAP c
g g g g g g g g g
ompletes another task. g g
b- Ask the UAP to use some of the pillows to prop the client in a side lyi
g g g g g g g g g g g g g g g g
ng position.
g
Rationale: The nurse should instruct the UAP to pad the side rails with soft bla
g g g g g g g g g g g g g g
nkest because the use of pillows could result in suffocation and would need to
g g g g g g g g g g g g g g
be removed at the onset of the seizure. The nurse can delegate paddling the sid
g g g g g g g g g g g g g g
e rails to the UAP
g g g g
4. An adolescent with major depressive disorder has been taking dulo
g g g g g g g g g
xetine (Cymbalta) for the past 12 days. Which assessment finding re
g g g g g g g g g g
quires immediate follow-up?
g g
a- Describes life without purpose g g g
b- Complains of nausea and loss of appetite c- g g g g g g g
g States is often fatigued and drowsy d-
g g g g g g
g Exhibits an increase in sweating.
g g g g
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptak
g g g g g g g g
e inhibitor that is known to increase the risk of suicidal thinking in adole
g g g g g g g g g g g g g
scents and young adults with major depressive
g g g g g g
, disorder. B, C and D are side effectsg g g g g g g
5. A 60-year- g
old female client with a positive family history of ovarian cancer
g g g g g g g g g g g
has developed an abdominal mass and is being evaluated for pos
g g g g g g g g g g
sible ovarian cancer. Her Papanicolau (Pap) smear results are n
g g g g g g g g g
egative. What information should the nurse include in the client’
g g g g g g g g g
s teaching plan?
g g
a- Further evaluation involving surgery may be needed
g g g g g g
b- A pelvic exam is also needed before cancer is ruled out c-
g g g g g g g g g g g
g Pap smear evaluation should be continued every six month d-
g g g g g g g g g
g One additional negative pap smear in six months is needed.
g g g g g g g g g
Rationale: An abdominal mass in a client with a family history for ovaria
g g g g g g g g g g g g
n cancer should be evaluated carefully
g g g g g
6. A client who recently underwear a tracheostomy is being pre
g g g g g g g g g
pared for discharge to home. Which instructions is most imp
g g g g g g g g g
ortant for the nurse to include in the discharge plan?
g g g g g g g g g
a- Explain how to use communication tools. b-
g g g g g g
gTeach tracheal suctioning techniques c-
g g g g
gEncourage self-care and independence. g g g
d- Demonstrate how to clean tracheostomy site.
g g g g g g
(750 QUESTIONS AND ANSWERS, RATIONALE OF EAC
g g g g g g
H ANSWER INCLUDED)
g g
1. Following discharge teaching, a male client with duodenal ulcer tells t
g g g g g g g g g g
he nurse the he will drink plenty of dairy products, such as milk, to hel
g g g g g g g g g g g g g g
p coat and protect his ulcer. What is the best follow-
g g g g g g g g g g
up action by the nurse?
g g g g
a- Remind the client that it is also important to switch to decaffeinated c
g g g g g g g g g g g g
offee and tea. g g
b- Suggest that the client also plan to eat frequent small meals to re
g g g g g g g g g g g g
duce discomfort g
c- Review with the client the need to avoid foods that are rich in m
g g g g g g g g g g g g g
ilk and cream.
g g
d- Reinforce this teaching by asking the client to list a dairy food that he mi
g g g g g g g g g g g g g g
ght select.
g
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and sho
g g g g g g g g g g g g
uld be avoided.
g g
2. A male client with hypertension, who received new antihypertensive p
g g g g g g g g g
rescriptions at his last visit returns to the clinic
g g g g g g g g
, two weeks later to evaluate his blood pressure (BP). His BP is 158/106 a
g g g g g g g g g g g g g
nd he admits that he has not been taking the prescribed medication bec
g g g g g g g g g g g g
ause the drugs make him “feel bad”. In explaining the need for hyperte
g g g g g g g g g g g g
nsion control, the nurse should stress that an elevated BP places the clie
g g g g g g g g g g g g
nt at risk for which pathophysiological condition?
g g g g g g
a- Blindness secondary to cataracts b- g g g g
Acute kidney injury due to glomerular damage c-
g g g g g g g g
gStroke secondary to hemorrhage d- g g g g
gHeart block due to myocardial damage
g g g g g
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
g g g g g g g g g g g
hypertension.
3. The nurse observes an unlicensed assistive personnel (UAP) position
g g g g g g g g
ing a newly admitted client who has a seizure disorder. The client is s
g g g g g g g g g g g g g
upine and the UAP is placing soft pillows along the side rails. What a
g g g g g g g g g g g g g
ction should the nurse implement?
g g g g
a- Ensure that the UAP has placed the pillows effectively to protect the cl
g g g g g g g g g g g g
ient.
b- Instruct the UAP to obtain soft blankets to secure to the side rails
g g g g g g g g g g g g
, instead of pillows. g g
a- Assume responsibility for placing the pillows while the UAP c
g g g g g g g g g
ompletes another task. g g
b- Ask the UAP to use some of the pillows to prop the client in a side lyi
g g g g g g g g g g g g g g g g
ng position.
g
Rationale: The nurse should instruct the UAP to pad the side rails with soft bla
g g g g g g g g g g g g g g
nkest because the use of pillows could result in suffocation and would need to
g g g g g g g g g g g g g g
be removed at the onset of the seizure. The nurse can delegate paddling the sid
g g g g g g g g g g g g g g
e rails to the UAP
g g g g
4. An adolescent with major depressive disorder has been taking dulo
g g g g g g g g g
xetine (Cymbalta) for the past 12 days. Which assessment finding re
g g g g g g g g g g
quires immediate follow-up?
g g
a- Describes life without purpose g g g
b- Complains of nausea and loss of appetite c- g g g g g g g
g States is often fatigued and drowsy d-
g g g g g g
g Exhibits an increase in sweating.
g g g g
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptak
g g g g g g g g
e inhibitor that is known to increase the risk of suicidal thinking in adole
g g g g g g g g g g g g g
scents and young adults with major depressive
g g g g g g
, disorder. B, C and D are side effectsg g g g g g g
5. A 60-year- g
old female client with a positive family history of ovarian cancer
g g g g g g g g g g g
has developed an abdominal mass and is being evaluated for pos
g g g g g g g g g g
sible ovarian cancer. Her Papanicolau (Pap) smear results are n
g g g g g g g g g
egative. What information should the nurse include in the client’
g g g g g g g g g
s teaching plan?
g g
a- Further evaluation involving surgery may be needed
g g g g g g
b- A pelvic exam is also needed before cancer is ruled out c-
g g g g g g g g g g g
g Pap smear evaluation should be continued every six month d-
g g g g g g g g g
g One additional negative pap smear in six months is needed.
g g g g g g g g g
Rationale: An abdominal mass in a client with a family history for ovaria
g g g g g g g g g g g g
n cancer should be evaluated carefully
g g g g g
6. A client who recently underwear a tracheostomy is being pre
g g g g g g g g g
pared for discharge to home. Which instructions is most imp
g g g g g g g g g
ortant for the nurse to include in the discharge plan?
g g g g g g g g g
a- Explain how to use communication tools. b-
g g g g g g
gTeach tracheal suctioning techniques c-
g g g g
gEncourage self-care and independence. g g g
d- Demonstrate how to clean tracheostomy site.
g g g g g g
