HESI 1 EXIT RN V4 QUESTIONS

1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? - Make certain the child is maintained in correct body alignment 2. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider? - Height and weight percentiles vary widely 3. . The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? - advise the parents to ignore breath holding because breathing will begin as a reflex 4. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? - My pain is deep in my chest behind my sternum 5. Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? - checking the clients blood pressure 6. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? - "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." 7. 2-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: - Ask the answering service to contact the on-call physician 8. An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: - Ask the ED physician to check the client 9. NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: - Administer the antihypertensive with a small sip of water 10. A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? - " Tell me more about what you're feeling" 11. A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse's priority? - contacting the physician 12. A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: - Call the radiography department to obtain a chest x-ray 13. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? - Safety 14. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? - They are able to think logically in organizing facts 15. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to - An occupational therapist from the community center 16. A priority goal of involuntary hospitalization of the severely mentally ill client is - Protection from harm to self or others 17. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend - isometric 18. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report - Loss of consciousness 19. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would - Administer a laxative to the client the evening before the examination 20. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? - Risk for infection