HESI EXIT 2023 LATEST

HESI EXIT 2023 LATEST A morbidly obese client is scheduled for gastric bypass surgery. The client completes the required preoperative nutritional counseling and signs the operative permit. To promote effective discharge planning, which intervention is most important for the nurse to implement? - CORRECT ANSWER-Discuss small, low fat, low sugar meal preparation techniques. A client who was splashed with a chemical has both eyes covered with bandages. When assisting the client with eating, which intervention should the nurse instruct the UAP to implement? - CORRECT ANSWER-Orient the client to the location of the food on the plate. A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all that apply.) - CORRECT ANSWER-• Observe for evidence of hypokalemia • Teach the client how to restrict dietary sodium • Weight the client daily, in the morning While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take? - CORRECT ANSWER-Administer prescribed antibiotics. A client who has asthma receives a new prescription for a corticosteroid inhaler. The client expresses concern about taking steroid medications. What information should the nurse provide the client about the use of this maintenance inhaler? - CORRECT ANSWER-Systemic side effects are reduced when taken by inhalation The healthcare provider prescribes a sedative for a client with severe hypothyroidism. The nurse plans to contact the provider to review the safety of the prescription for the client and consults first with the charge nurse. The charge nurse notes that the prescription is written legally and completely. How should the charge nurse respond? - CORRECT ANSWER-Assume responsibility for discussing the concern with the provider. In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. Which action should the nurse implement? - CORRECT ANSWER-Ensure that no dependent loops are present in the tubing. Which information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? - CORRECT ANSWER-Use cold and allergy medications only as directed by a healthcare provider. A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? (Select all that apply) - CORRECT ANSWER-• Monitor stools for presence of blood • Auscultate bowel sounds in all quadrants • Review last partial thromboplastin time results. Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)? - CORRECT ANSWER-• Serum potassium, calcium, and phosphorus. A mal client who was in a motor vehicle collision yesterday is receiving a unit of packed red blood cells. When half of the unit is infused, the client reports lower back pain, and the nurse observes a fine rash over his chest and back. Which intervention should the nurse implement? - CORRECT ANSWER-Replace the transfusion with normal saline When developing a teaching plan for a client with newly diagnosed Type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs? - CORRECT ANSWER-Give a dose of regular insulin as prescribed Which information is most important to include in the teaching plan for a client who is discharged after a thyroidectomy for Grave's disease? - CORRECT ANSWER-Daily hormone replacement will be needed for the rest of the client's life. The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting exenatide. Which information should be included in the discharge instructions? - CORRECT ANSWER-Notify your healthcare provider if you start having abdominal pain. Which breakfast selection should he nurse recommend for a 16-year-old with diarrhea? - CORRECT ANSWER-Oatmeal, banana, and herbal tea. The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-monthold infant. Which action should the nurse include? - CORRECT ANSWER-Divide the medication into two injections with volumes under 1 mL. A school-aged child with chronic renal failure receives a prescription from the healthcare provider for losartan. Which action should the nurse implement prior to administering the medication? - CORRECT ANSWER-Evaluate the ability to swallow medication. An adolescent client on a drug treatment unit becomes angry and pulls the refrigerator from the wall and then throws the microwave. After the client fails to respond to the redirection, the healthcare provider prescribes restraints. Which assessment should the nurse include in the client's record while the client is in restraints? - CORRECT ANSWER-• Range-of-motion and circulation. The nurse brings an oral medication prescribed to be given daily to a male client who tells the nurse that he will take his medication later. Which action should the nurse implement? - CORRECT ANSWER-Agree upon a time to return to the client's room with the medication. When conducting diet teaching for a client who was diagnosed with hypertension, which foods should the nurse encourage the client to eat? (Select all that apply) - CORRECT ANSWER-• Fresh or frozen vegetables without sauce • Fruits without sauce The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse gathers equipment, including an intravenous catheter and insertion kit, and a 4x4 gauze dressing to apply over the insertion site. Which action should the charge nurse take? - CORRECT ANSWER-• Remind the nurse to use a transparent dressing over the site. The client who has emphysema and recently experienced a stroke receives a prescription for a metered-dose inhaler with a spacer device. The client asks the nurse if using the spacer is necessary. What information should the nurse provide? - CORRECT ANSWER-It allows time to inhale the entire dispensed dose. A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication? - CORRECT ANSWER-• Report unusual bruising or bleeding. An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which interventions should the nurse include in this client's plan of care? - CORRECT ANSWER-• Encourage family to bring the client old photographs • Encourage family to visit frequently • Teach the client how to use guided imagery The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching? - CORRECT ANSWER-Avoid straining at school, bending, or lifting heavy objects. The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client? - CORRECT ANSWER-Musical and drumlike. An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? - CORRECT ANSWER-• Teach the client to use incentive spirometer every 2 hours while awake. • Remove urinary catheter as soon as possible and encourage voiding. An older adult ids admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which interventions should the nurse include in the plan of care during convalescence and rehabilitation? - CORRECT ANSWER-• Place a bedside commode next to bed. • Encourage family to participate in the client's care. • Measure neurological vital signs every 4 hours. The nurse is triaging victims of an explosion from a housing area outside of town. The nurse should issue a black disaster tag to which client? - CORRECT ANSWER-• An older client with a head injury, fixed pupils and absent vital signs. A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider? - CORRECT ANSWER-Sharp fundal pain and uterine tenderness. A client is admitted to the labor and delivery unit in early labor and the nurse assesses the status of her contractions. The frequency of contractions is most accurately by counting the minutes and seconds in which manner? - CORRECT ANSWER-From the beginning of one contraction to the beginning of the next contraction. A postterm infant is delivered with meconium-stained skin and cord. The newborn is having substernal retractions, grunting, and nasal flaring. Surfactant is administered. Which statement should the nurse provide to the family about the purpose of surfactant? - CORRECT ANSWER-It increases lung compliance and decreases surface tension. A postpartum client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client? - CORRECT ANSWER-Avoid stimulation of the breasts and wear a tight bra. The nurse finds a client at 33-week gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? - CORRECT ANSWER-Position a firm wedge to support pelvis and thorax at 30 degree tilt. Six weeks after the birth of child with Trisomy 21, the parents return to the prenatal clinic for a follow-up visit. They have spoken with a genetic counselor, but are still unsure about the risk of having another clid with Trisomy 21. The couple begins literature form the counselor with them, and asks the nurse to explain it. Which actions should the nurse take? - CORRECT ANSWER-Review the literature and answer any questions the nurse is able to answer. A client hospitalized with pleural effusion has a history of heart failure. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care? - CORRECT ANSWER-Provide a bedside commode for toileting Two hours after an abdominal aneurysm repair, a client remains sedated and mechanically ventilated in the post-anesthesia care unit (PACU). Which assessment finding warrants immediate intervention by the nurse? - CORRECT ANSWER-Systolic blood pressure less than 90 mm Hg. An older adult male with the heart failure (HF) develops cardiac tamponade. After the healthcare provider performs pericardiocentesis, which intervention is most important for the nurse to implement? - CORRECT ANSWER-Monitor for recurrence of tamponade and cardiovascular collapse. A client is admitted with an exacerbation of heart failure secondary to COPD. Which observation by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply) - CORRECT ANSWER-• A full pitcher of water is on the bedside table. • The client is lying in a supine position in bed. A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately? - CORRECT ANSWER-Defibrillate with one shock. The nurse is providing teaching to a client about management of type 2 diabetes mellitus. Which information stated by the client indicates understanding? - CORRECT ANSWER-Avoid seasoning foods with salt and salt-containing spices A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first? - CORRECT ANSWER-Ensure client takes a diuretic every morning In providing nursing care for a client after gastric endoscopy, which commonly occurring problem should the nurse include interventions for in the post-procedure plan of care? - CORRECT ANSWER-Sore throat. While caring for a client who had an exploratory laparotomy yesterday, the nurse notes that coffee ground material is draining from the nasogastric tube. Which intervention should the nurse implement? - CORRECT ANSWER-Test nasogastric drainage for the presence of blood.