EXIT HESI 2022

EXIT HESI 2022 An older client's daughter calls the home health nurse and reports that her mother has become and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days a few days ago and is now getting worse. Which actions should the nurse take? Select all that apply a. Ask if the mother is experiencing any pain with urination. b. Encourage increase intake of high protein foods. c. Instruct the daughter to check her mother's temperature. d. Review the clients cur - CORRECT ANSWER-a. Ask if the mother is experiencing any pain with urination. c. Instruct the daughter to check her mother's temperature. e. Determine if the mother has recently experienced a fall. 1.The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis, which expected outcome has the highest priority. a. Identifies 2 treatments for Constipation due to immobility. b. Names three home safety hazards to be resolved immediately. c. States 4 risk factors for the development of osteoporosis. d. List five calcium rich foods to be added to her daily diet. - CORRECT ANSWER-b. Names three home safety hazards to be resolved immediately. 1. The nurse preparing a client who had a BKA ( below the knee amp) for discharge to home. Which recommendations should the nurse provide this client? (SATA) a. Avoid range of motion exercises b. Use residual limb shrinker c. Wash the stump with soap and water d. Inspect skin for redness e. Apply alcohol to the stump after bathing - CORRECT ANSWER-a. Inspect skin for redness b. Use a residual limb shrinker c. Wash the stump with soap and water A client's morning assessment includes bounding peripheral pulses, weight gain of 2lbs (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care? a. Restrict daily fluid intake to 1500 mL b. Administer prescribed diuretic c. Maintain accurate intake and output d. Weigh client every morning - CORRECT ANSWER-b. Administer prescribed diuretic The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement? A. Encourage family members to cook meals outdoors and bring the cooked food inside B. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting C. Assess the client's mucous membranes and report the findings to the HCP D. Advice the client to replace cooked foods with a variety - CORRECT ANSWER-A. Encourage family members to cook meals outdoors and bring the cooked food inside A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? A. administer hypertonic IV fluids as prescribed B. Limit fluid Intake Assess neurological status every 8 hours Initiate seizure precautions - CORRECT ANSWER-B. Limit fluid Intake A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent? a. distended tortuous veins in the left hand b. auscultation of the thrill in the left forearm c. the left radial pulse is 2+ bounding d. assessment of bruit on the left forearm - CORRECT ANSWER-d. assessment of bruit on the left forearm An older client arrives to the emergency department (ED) with reports of sever nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature 95.4 (35.2), heart rate 112 beats/min, respirations 14 breaths/minute, and blood pressure 74/37 mmHg. Which intervention is most important for the nurse to implement? a. Maintain Strict intake and output b. monitor blood glucose level c. keep head of bed raised 45 degrees d. assess warmth of extremities - CORRECT ANSWER-c. keep head of bed raised 45 degrees The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply a. Avoid prolonged standing or sitting b. Use recliner for long period of sitting c. continue wearing elastic stocking d. Maintain the bed flat while sleeping e. Cross legs at knee but not at ankle - CORRECT ANSWER-a. Avoid prolonged standing or sitting b. Use recliner for long period of sitting c. continue wearing elastic stocking During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? SATA. a. Natural whole almonds b. Cheddar cheese cubes c. slightly salted potato chips d. plain, air popped popcorn e. canned fruit in heavy syrup - CORRECT ANSWER-a. Natural whole almonds d. plain, air popped popcorn The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? a. aerobic exercise b. weight bearing exercise c. muscle stretching and toning d. core strengthening - CORRECT ANSWER-b. weight bearing exercise A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse? a. Low-grade fever, headache, and malaise for the past 72 hours b. Unable to bear weight on the left foot, with the swelling and bruising c. Chest discomfort one hour after consuming a large, spicy meal d. One-inch bleeding laceration on the chain of the crying five-year-old - CORRECT ANSWER-c. Chest discomfort one hour after consuming a large, spicy meal An adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply a. History of hypertension. b. Homosexual lifesty - CORRECT ANSWER-a. History of hypertension. e. Family heath history. A nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? SATA. a. Leans forward to pull from the high shelf b. bends from the waist to pick trash off the floor c. locks knees while preparing food on the counter d. brings the heavy can close to body before lifting e. Widens stance while working near the sink. - CORRECT ANSWER-d. brings the heavy can close to body before lifting e. Widens stance while working near the sink. The nurse is feeding a client who was admitted this morning with syncope and generalized weakness. The client has a history of aspiration and begins coughing while attempting to drink through a straw. Which action should the nurse implement? a. Elevate head of bed for 30 minutes after meals. b. Perform oral care before meals. c. Allow small amount of liquids with meals. d. Provide nectar thickened liquids - CORRECT ANSWER-d. Provide nectar thickened liquids After receiving report on an inpatient acute care unit, which client should the nurse assess first? a. the client with a small bowel obstruction who has a nasogastric tube that is draining green fluid b. the client with a bowel obstruction due to a volvulus who is experiencing abnormal rigidity c. the client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds d. the client with an obstruction of the large intestine who is experiencing abdominal distention. - CORRECT ANSWER-b. the client with a bowel obstruction due to a volvulus who is experiencing abnormal rigidity