2019 PN Hesi Exit V1

2019 PN Hesi Exit V1Question 1 A school-age client with diabetes is placed on an intermediateacting insulin and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. What does the nurse tell the client the snack is intended to do? You Selected: • Prevent late night hypoglycemia. Correct response: • Prevent late night hypoglycemia. Question 2 A well-known public official of a small community is admitted to the emergency department following an episode of chest pain. Several nurses from the medical unit are aware of the admission and access the official’s electronic medical record to obtain a status update. What is the best response for the nurse manager to make to the nurses regarding this situation? You Selected: • “Assessing the official’s medical record is a breach of confidentiality.” Correct response: • “Assessing the official’s medical record is a breach of confidentiality.” Question 3 A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell (WBC) count, especially the neutrophil count, is low. What is the most important intervention thenurse should teach the parents? You Selected: • Protect your child from infections because his resistance to infection is decreased Correct response: • Protect your child from infections because his resistance to infection is decreased Question 4 The nurse is caring for a client with influenza. The most effective way to decrease the spread of microorganisms is: You Selected: • placing the client in isolation. Correct response: • washing the hands frequently. 1 | P a g eQuestion 5 A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure? You Selected: • in the supine, sitting, and standing positions Correct response: • in the supine, sitting, and standing positions Question 6 A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further? You Selected: • cool, pale fingers Correct response: • cool, pale fingers Question 7 A nurse is caring for a female client before surgery. The client states that she is glad that she will not be going through menopause as a result of her surgery and is only having her uterus removed. The nurse reviews the consent form and notes that the surgery is for a total abdominal hysterectomy with a salpingo-oophorectomy. What should the nurse do in this situation? You Selected: • Contact the surgeon to explain that the client needs further clarification regarding surgery. Correct response: • Contact the surgeon to explain that the client needs further clarification regarding surgery. Question 8 A young client diagnosed with schizophrenia is talking with the nurse and says, "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I would like to get out and do things again." What is the best initial response by the nurse? You Selected: 2 | P a g e• "What activities did you enjoy in the past?" Correct response: • "What activities did you enjoy in the past?" Question 9 A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia? You Selected: • nausea, vomiting, and anorexia Correct response: • dyspnea, tachycardia, and pallor Question 10 The nurse is discontinuing an intravenous catheter on a 10-year-old client with hemophilia. What would be the most important intervention for this client? You Selected: • Apply firm pressure on the site for 5 minutes after removal. Correct response: • Apply firm pressure on the site for 5 minutes after removal. Question 11 When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse’s priority assessment? You Selected: • checking the dressing, drain, and amount of drainage Correct response: • assessing the vital signs and oxygen saturation levels Question 12 3 | P a g eA client with an uncomplicated term pregnancy arrives at the labor- and-delivery unit in early labor saying that she thinks her water has broken. What is the nurse’s best action? You Selected: • Ask what time this happened and note the color, amount, and odor of the fluid. Correct response: • Ask what time this happened and note the color, amount, and odor of the fluid. Question 13 When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: You Selected: • ensuring the abbreviations are understandable to clients who may seek access to their health records Correct response: • limiting abbreviations to those approved for use by the institution Question 14 During routine prenatal screening, a nurse tells a client that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates? You Selected: • "This screening indicates if your baby's lungs are mature." Correct response: • "This test will screen for spina bifida, Down syndrome, or other genetic defects." Question 15 A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? You Selected: • chicken and orange slices Correct response: 4 | P a g e• chicken and orange slices Question 16 A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse? You Selected: • Collaborate with the interprofessional team to make a referral to social services. Correct response: • Collaborate with the interprofessional team to make a referral to social services. Question 17 A client is newly diagnosed with asthma. While learning to use a metered dose inhaler (MDI) for delivery of a short-term beta agonist, the client asks if a spacer is appropriate to use with this device. What is the nurse’s best response? You Selected: • “No, a spacer is not recommended because it can increase the risk of developing oropharyngeal candidiasis.” Correct response: • “Yes, a spacer is recommended because it increases theamount of medication that is delivered to the lungs.” Question 18 5 | P a g eThe nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client’s pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client’s vital signs, and the client’s score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. What should the nurse do next? You Selected: • Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed. Correct response: • Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed. Question 19 The nurse is making a room assignment for a client whose laboratory test result indicate pancytopenia. Which client should the nurse put into the same room with the client with pancytopenia? You Selected: • a client with digoxin toxicity Correct response: • 6 | P a g ea client with digoxin toxicity Question 20 A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which of the following? You Selected: • A referral. Correct response: • A referral. Question 21 A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first? You Selected: • the client admitted after a head injury in a motor vehicle who reports nausea Correct response: • the client admitted after a head injury in a motor vehicle who reports nausea Question 22 The mother of an adolescent client who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which response by the nurse is appropriate? You Selected: • 7 | P a g e“Tell me what you’ve found in your reading