HESI 799 RN Exit Exam QUESTIONS AND CORRECT
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A client on a long-term mental health unit repeatedly takes own pulse regardless of the
circumstance. What action should the nurse implement?
a. Overlook the client's behavior.
b. Distract client to interfere with the ritual.
c. Ask why the client checks the pulse.
d. Hold client's hand to stop the behavior.
Overlook the client's behavior.
A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which
instructions should the nurse include?
a. Wash hands before cleaning exit site
b. Keep the head of the bed flat at night
c. Feel for a thrill and a distal pulse nightly
d. Do not get up if fluid is left in the abdomen
Wash hands before cleaning exit site
Rationale: meticulous hand hygiene is essential when performing care for a peritoneal dialysis,
infections is a common complication of peritoneal dialysis.
,The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for
performing a sterile dressing change. Which action by the PN requires correction by the charge
nurse?
a- Opening the package
b- Picking up the second glove
c- Picking up the first glove
d- Positioning of the table
Picking up the second glove
A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious
when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of
closed head injury. Which assessment finding is indicative of a developing epidural hematoma?
a. Altered consciousness within the first 24 hours after injury.
b. Cushing reflex and cerebral edema after 24 hours
c. Fever, nuchal rigidity and opisthotonos within hours
d. Headache and pupillary changes 48 hours after a head injury
Altered consciousness within the first 24 hours after injury.
A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his
blood pressure is elevated. Based on this findings, this client is at a greatest risk for which
pathophysiological condition?
a. Pulmonary hypertension
b. Left ventricular hypertrophy
c. Renal failure
,d. Stroke
Stroke
The nurse ask the parent to stay during the examination of a male toddler's genital area. Which
intervention should the nurse implement?
a. Examine the genitalia as the last part of the total exam.
b. Use soothing statements to facilitate cooperation
c. Allow the child to keep underpants on to examine genitalia
d. Work slowly and methodically so not to stress the child
Examine the genitalia as the last part of the total exam.
Rationale: Examination of a child's genitalia is particularly stressful to toddles, so this
assessment is best left as the last part of the examination. B are best done by a parent, not the
nurse. The genitals must be completely visualized and sometimes palpates underwear for a brief
period of.
The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup
when the bag of solution is _____. Which action should the nurse take to ensure adequate filling
of the drip chamber?
a. Lower the IV bag to a flat surface
b. Compress the drip chamber
c. Open the roller clamp
d. Squeeze the bag of IV solution
Compress the drip chamber
, During an Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic
hyperosmolar syndrome in addition to the client's glucose, which laboratory value is most
important for the nurse to monitor?
a. Urine ketones
b. Urine albumin
c. Serum protein
d. Serum potassium
d. Serum potassium
Rationale: Electrolyte shifts are common during correction of hyperosmolar and hyperglycemic
states. Monitor electrolyte levels at least every 4 hours, or every 2 hours if needed. Monitor
serum sodium and potassium levels closely. If needed, use isotonic and hypotonic saline
solutions to adjust the patient's sodium level. Despite major potassium loss during diuresis in
early HHS stages, many patients initially present in a hyperkalemic state due to dehydration.
When fluid and insulin therapy begin, the serum potassium level may drop dramatically.
In planning strategies to reduce a client's risk for complications following orthopedic surgery, the
nurse recognizes which pathology as the underlying cause of osteomyelitis?
a. Infectious process
b. Metastatic process
c. Autoimmune disorder
d. Inflammatory disorder
infectious process
DETAILED ANSWERS LATEST AND COMPREHENSIVE
VERSION GUARANTEED PASS WITH INSTANT PDF
DOWNLOAD!!
A client on a long-term mental health unit repeatedly takes own pulse regardless of the
circumstance. What action should the nurse implement?
a. Overlook the client's behavior.
b. Distract client to interfere with the ritual.
c. Ask why the client checks the pulse.
d. Hold client's hand to stop the behavior.
Overlook the client's behavior.
A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which
instructions should the nurse include?
a. Wash hands before cleaning exit site
b. Keep the head of the bed flat at night
c. Feel for a thrill and a distal pulse nightly
d. Do not get up if fluid is left in the abdomen
Wash hands before cleaning exit site
Rationale: meticulous hand hygiene is essential when performing care for a peritoneal dialysis,
infections is a common complication of peritoneal dialysis.
,The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for
performing a sterile dressing change. Which action by the PN requires correction by the charge
nurse?
a- Opening the package
b- Picking up the second glove
c- Picking up the first glove
d- Positioning of the table
Picking up the second glove
A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious
when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of
closed head injury. Which assessment finding is indicative of a developing epidural hematoma?
a. Altered consciousness within the first 24 hours after injury.
b. Cushing reflex and cerebral edema after 24 hours
c. Fever, nuchal rigidity and opisthotonos within hours
d. Headache and pupillary changes 48 hours after a head injury
Altered consciousness within the first 24 hours after injury.
A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his
blood pressure is elevated. Based on this findings, this client is at a greatest risk for which
pathophysiological condition?
a. Pulmonary hypertension
b. Left ventricular hypertrophy
c. Renal failure
,d. Stroke
Stroke
The nurse ask the parent to stay during the examination of a male toddler's genital area. Which
intervention should the nurse implement?
a. Examine the genitalia as the last part of the total exam.
b. Use soothing statements to facilitate cooperation
c. Allow the child to keep underpants on to examine genitalia
d. Work slowly and methodically so not to stress the child
Examine the genitalia as the last part of the total exam.
Rationale: Examination of a child's genitalia is particularly stressful to toddles, so this
assessment is best left as the last part of the examination. B are best done by a parent, not the
nurse. The genitals must be completely visualized and sometimes palpates underwear for a brief
period of.
The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup
when the bag of solution is _____. Which action should the nurse take to ensure adequate filling
of the drip chamber?
a. Lower the IV bag to a flat surface
b. Compress the drip chamber
c. Open the roller clamp
d. Squeeze the bag of IV solution
Compress the drip chamber
, During an Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic
hyperosmolar syndrome in addition to the client's glucose, which laboratory value is most
important for the nurse to monitor?
a. Urine ketones
b. Urine albumin
c. Serum protein
d. Serum potassium
d. Serum potassium
Rationale: Electrolyte shifts are common during correction of hyperosmolar and hyperglycemic
states. Monitor electrolyte levels at least every 4 hours, or every 2 hours if needed. Monitor
serum sodium and potassium levels closely. If needed, use isotonic and hypotonic saline
solutions to adjust the patient's sodium level. Despite major potassium loss during diuresis in
early HHS stages, many patients initially present in a hyperkalemic state due to dehydration.
When fluid and insulin therapy begin, the serum potassium level may drop dramatically.
In planning strategies to reduce a client's risk for complications following orthopedic surgery, the
nurse recognizes which pathology as the underlying cause of osteomyelitis?
a. Infectious process
b. Metastatic process
c. Autoimmune disorder
d. Inflammatory disorder
infectious process
