Exit HESI (Actual hesi hints), EXIT HESI 2

Exit HESI (Actual hesi hints), EXIT HESI 23 Middle ear bones - Incus, Maleus (hammer), Stapes 4 pts in ER 15 min apart, who do you see first? - 2 year old with Stridor 5 variables of biophysical profile - 1. Fetal breathing movements 2. Gross body movements 3. Fetal tone 4. Reactive FHR 5. Qualitative amniotic fluid volume 11 year old client - how to get him to verbalize ways to deal with things at home? - Play a board game 18 year old being assessed.. what needs to be reported to hCP right away? - large, warm tender preauricular nodes 191. The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) - Murmur 212. The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) - 1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia 217. When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sign of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur? - Give a dose of regular insulin per sliding scale 224. The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? - Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation onlystudents A 26-year-old woman comes to the emergency room for a possible ruptured ectopic pregnancy. On admission, the client's vital signs are pulse 90, blood pressure 110/70, respirations 20. A half-hour later, her vital signs are pulse 120, blood pressure 86/50, respirations 26. Which of the following is the MOST appropriate initial action for the nurse to take? 1. Administer pain medication. 2. Increase the rate of the IV fluids. 3. Ask the client to identify where she is. 4. Check the client's white cell count. - Implementation: outcome not desired; address ABCs first; analgesic medication may cause further decrease in blood pressure 2) CORRECT-Implementation: outcome desired and priority; increased pulse, decreased BP indicates decreased intravascular volume; symptoms of hypovolemic shock 3) Assessment: outcome desired but not priority; client in shock, implementation required 4) Assessment: outcome desired but not priority; usually won't change unless infection is causing septic shock A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? - Determine the client's vital sign. A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug? - Maternal pulse rate of 162 beats per min A client had a right kidney transplant 1 week ago. Which symptom, if experienced by the client, indicates to the nurse that the client is experiencing rejection? 1. The client complains of generalized muscle weakness. 2. The client complains of diffuse pain over the right abdomen. 3. The client gets up twice each night to void. 4. The client has lost 3 pounds. - 1) Assessment: outcome not priority; seen with electrolyte imbalance, not rejection 2) CORRECT-Assessment: outcome priority and expected with kidney rejection; tenderness over kidney is sign of rejection 3) Assessment: outcome not expected; oliguria is seen with rejection due to failing kidney 4) Assessment: outcome not expected; edema and weight gain are seen with rejection onlystudents a client in hypovolemic shock would present with what? - weak thready pulse a client is having a precipitate delivery and you are waiting for the doctor. how do you position the client? - lateral sims A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer? - Simethicone (Mylicon) a client who has a family history of malignant hyperthermia is going in to surgery and receiving general anesthesia. how do you prepare? - cooling blanket fluids a client who is bipolar is going home for the weekend to adjust for discharge. what do you tell the family? - continue normal daily activities A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care? - Provide daily care of tong insertion sites using saline and antibiotic ointment A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? - Confirm the desired effect of the medication has been achieved. A client with an 8-year history of ulcerative coliti