Exit Hesi w h o r e
The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns
that the client has a current blood glucose level of 750 mg/dL. (42 mmol/L). When assessing the
client, what is the priority?
A) Assess for signs of fluid volume deficit.
B) Observe wound drainage characteristics.
C) Measure the level of acute pain.
D) Determine when the client last ate. - ANSA) Assess for signs of fluid volume deficit.
A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he
is experiencing heartburn and a dull gnawing pain that is relieved when he eats. Which is the
best response by the nurse?
A) Encourage the client to obtain a complete physical exam, since these symptoms are
consistent with an ulcer.
B) Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved
with food.
C) Instruct the client that these mild symptoms can generally be controlled with changed in his
diet.
D) Advise the client that he needs to seek immediate medical evaluation and treatment of these
symptoms. - ANSA) Encourage the client to obtain a complete physical exam, since these
symptoms are consistent with an ulcer.
A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One
hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the
client's heart rate is 155bpm, and his blood pressure is 78/48 mmHg. In addition to reporting the
findings to the surgeon, which action should the nurse implement first?
A) Measure and document the client's urinary output.
B) Request the client's reserved unit of packed red blood cells.
C) prepare for placement of a central venous catheter.
D) Increase the infusion rate of Lactated Ringer's solution. - ANSD) Increase the infusion rate of
Lactated Ringer's solution.
A heparin infusion is prescribed for a client who weighs 220 pounds. After adminstering a bolus
dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution at 18
units/kg/hour. the available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection
250mL. The nurse should program the infusion pump to deliver how many ml/hour? Round to
nearest whole number if necessary. - ANS18
,An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to
the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the
-20 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 mL of bright red
blood is measured in the collection chamber. Which intervention should the nurse implement?
A) Add sterile water to the suction control chamber.
B) Give blood from the collection chamber as autotransfusion.
C) Manipulate blood tubing to drain into chamber.
D) Increase wall suction to eliminate fluctuation in water seal. - ANSA) Add sterile water to the
suction control chamber.
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches
the nurse and asks how she will know that her husband's death is imminent because their two
children want to be there when he dies. Which is the best response by the nurse?
A) Gather information regarding how long it will take for the children to arrive.
B) Explain that the client will start to lose consciousness and the body systems will slow down.
C) Reassure the spouse that the healthcare provider will notify when to call the children.
D) Offer to discuss the client's health status with each of the adult children. - ANSB) Explain that
the client will start to lose consciousness and the body systems will slow down.
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the
optimal number of registered nurses will be working that shift. In planning assignments, which
client should receive the most care hours by a registered nurse (RN)?
A) A 48-year-old marathon runner with a central venous catheter who is experiencing nausea
and vomiting due to electrolyte disturbance following a race.
B) A 34-year-old admitted today after an emergency appendectomy who has a peripheral
intravenous catheter and a Foley catheter.
C) A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via
nasal cannula and has a saline-locked peripheral intravenous catheter.
D) An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has a Foley
catheter and soft wrist restraints applied. - ANSD) An 82-year-old client with Alzheimer's
disease and a newly-fractured femur who has a Foley catheter and soft wrist restraints applied.
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2/4
mL." How many mL should the nurse administer? if needed, round to the nearest tenth.) -
ANS0.2
In caring for a client with Cushing's syndrome, which serum laboratory value is most important
for the nurse to monitor?
,A) Creatinine
B) Lactate
C) Glucose
D) Hemoglobin - ANSC) Glucose
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 bpm, and respiratory rate 36 breathe/minute. The client manifesting
shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%.
Which action should the nurse take first?
A) Elevate the foot of the bed.
B) Restrict the client's fluids.
C) Begin supplemental oxygen.
D) prepare client for hemodialysis. - ANSC) Begin supplemental oxygen.
When caring for a client with full-thickness burns to both lower extremities, which assessment
findings warrant immediate intervention? Select all that apply.
A) Sloughing tissue around wound edges.
B) Complaint of increased pain and pressure.
C) Change in the quality of the peripheral pulses.
D) Loss of sensation to the left lower extremity.
E) Weeping serosanguineous fluid from wounds. - ANSB) Complaint of increased pain and
pressure.
C) Change in the quality of the peripheral pulses.
D) Loss of sensation to the left lower extremity.
An older client is admitted with fluid volume deficit and dehydration. Which assessment finding
is the best indicator that the nurse should report to the healthcare provider?
A) Urine specific gravity is 1.040.
B) Systolic blood pressure decreases 10 points when standing.
C) The client denies being thirsty.
D) Skin tenting occurs when the client's forearm is pinched. - ANSD) Skin tenting occurs when
the client's forearm is pinched.
The healthcare provider prescribes methylergonovine maleate for a postpartum client with
uterine atony. What finding should indicate to the nurse to withhold the next dose of the
medication?
A) Difficulty locating for uterine fundus.
B) Excessive lochia.
C) Saturation of more than one pad per hour.
D) Hypertension - ANSD) Hypertension
, After an inservice about electronic health record (EHR) security and safeguarding client
information, the nurse observes a colleague going home with printed copies of client information
in a uniform jacket. Which action should the nurse take?
A) File a detailed incident report with the specific hiring facility.
B) Warn the colleague that their actions are unprofessional.
C) Comment anonymously about the action on a staff discussion board.
D) Communicate the colleague's actions to the unit charge nurse. - ANSA) File a detailed
incident report with the specific hiring facility.
The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease
implemented in a rural health clinic. Which outcome indicates the program is effective?
A) At-risk clients received an increased number of routine health screenings.
B) Clients reported having new confidence in making healthy food choices.
C) Clients who incurred disease complications promptly received rehabilitation.
D) Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign. - ANSC)
Clients who incurred disease complications promptly received rehabilitation.
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the
wound. before reporting this finding to the healthcare provider, the nurse should review which of
the client's laboratory values?
A) Culture for sensitive organisms.
B) Serum blood glucose (BG) level.
C) Creatinine level.
D) Serum albumin. - ANSA) Culture for sensitive organisms.
A client is admitted with acute pancreatitis. the client admits to drinking a pint of bourbon daily.
The nurse medicates the client for pain and monitors vital signs every 2 hours. Which finding
should the nurse report immediately to the healthcare provider?
A) Anorexia and abdominal distention.
B) Abdominal pain and vomiting.
C) Confusion and tremors.
D) Yellowing and itching of skin. - ANSC) Confusion and tremors.
A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count
of 25,000/mm^3 (25 x 10^9/L). Which intervention is most important for the nurse to include in
this client's plan of care?
A) Assess urine and stool for occult blood.
B) Monitor for signs of activity intolerance.
The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns
that the client has a current blood glucose level of 750 mg/dL. (42 mmol/L). When assessing the
client, what is the priority?
A) Assess for signs of fluid volume deficit.
B) Observe wound drainage characteristics.
C) Measure the level of acute pain.
D) Determine when the client last ate. - ANSA) Assess for signs of fluid volume deficit.
A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he
is experiencing heartburn and a dull gnawing pain that is relieved when he eats. Which is the
best response by the nurse?
A) Encourage the client to obtain a complete physical exam, since these symptoms are
consistent with an ulcer.
B) Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved
with food.
C) Instruct the client that these mild symptoms can generally be controlled with changed in his
diet.
D) Advise the client that he needs to seek immediate medical evaluation and treatment of these
symptoms. - ANSA) Encourage the client to obtain a complete physical exam, since these
symptoms are consistent with an ulcer.
A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One
hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the
client's heart rate is 155bpm, and his blood pressure is 78/48 mmHg. In addition to reporting the
findings to the surgeon, which action should the nurse implement first?
A) Measure and document the client's urinary output.
B) Request the client's reserved unit of packed red blood cells.
C) prepare for placement of a central venous catheter.
D) Increase the infusion rate of Lactated Ringer's solution. - ANSD) Increase the infusion rate of
Lactated Ringer's solution.
A heparin infusion is prescribed for a client who weighs 220 pounds. After adminstering a bolus
dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution at 18
units/kg/hour. the available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection
250mL. The nurse should program the infusion pump to deliver how many ml/hour? Round to
nearest whole number if necessary. - ANS18
,An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to
the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the
-20 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 mL of bright red
blood is measured in the collection chamber. Which intervention should the nurse implement?
A) Add sterile water to the suction control chamber.
B) Give blood from the collection chamber as autotransfusion.
C) Manipulate blood tubing to drain into chamber.
D) Increase wall suction to eliminate fluctuation in water seal. - ANSA) Add sterile water to the
suction control chamber.
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches
the nurse and asks how she will know that her husband's death is imminent because their two
children want to be there when he dies. Which is the best response by the nurse?
A) Gather information regarding how long it will take for the children to arrive.
B) Explain that the client will start to lose consciousness and the body systems will slow down.
C) Reassure the spouse that the healthcare provider will notify when to call the children.
D) Offer to discuss the client's health status with each of the adult children. - ANSB) Explain that
the client will start to lose consciousness and the body systems will slow down.
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the
optimal number of registered nurses will be working that shift. In planning assignments, which
client should receive the most care hours by a registered nurse (RN)?
A) A 48-year-old marathon runner with a central venous catheter who is experiencing nausea
and vomiting due to electrolyte disturbance following a race.
B) A 34-year-old admitted today after an emergency appendectomy who has a peripheral
intravenous catheter and a Foley catheter.
C) A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via
nasal cannula and has a saline-locked peripheral intravenous catheter.
D) An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has a Foley
catheter and soft wrist restraints applied. - ANSD) An 82-year-old client with Alzheimer's
disease and a newly-fractured femur who has a Foley catheter and soft wrist restraints applied.
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2/4
mL." How many mL should the nurse administer? if needed, round to the nearest tenth.) -
ANS0.2
In caring for a client with Cushing's syndrome, which serum laboratory value is most important
for the nurse to monitor?
,A) Creatinine
B) Lactate
C) Glucose
D) Hemoglobin - ANSC) Glucose
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 bpm, and respiratory rate 36 breathe/minute. The client manifesting
shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%.
Which action should the nurse take first?
A) Elevate the foot of the bed.
B) Restrict the client's fluids.
C) Begin supplemental oxygen.
D) prepare client for hemodialysis. - ANSC) Begin supplemental oxygen.
When caring for a client with full-thickness burns to both lower extremities, which assessment
findings warrant immediate intervention? Select all that apply.
A) Sloughing tissue around wound edges.
B) Complaint of increased pain and pressure.
C) Change in the quality of the peripheral pulses.
D) Loss of sensation to the left lower extremity.
E) Weeping serosanguineous fluid from wounds. - ANSB) Complaint of increased pain and
pressure.
C) Change in the quality of the peripheral pulses.
D) Loss of sensation to the left lower extremity.
An older client is admitted with fluid volume deficit and dehydration. Which assessment finding
is the best indicator that the nurse should report to the healthcare provider?
A) Urine specific gravity is 1.040.
B) Systolic blood pressure decreases 10 points when standing.
C) The client denies being thirsty.
D) Skin tenting occurs when the client's forearm is pinched. - ANSD) Skin tenting occurs when
the client's forearm is pinched.
The healthcare provider prescribes methylergonovine maleate for a postpartum client with
uterine atony. What finding should indicate to the nurse to withhold the next dose of the
medication?
A) Difficulty locating for uterine fundus.
B) Excessive lochia.
C) Saturation of more than one pad per hour.
D) Hypertension - ANSD) Hypertension
, After an inservice about electronic health record (EHR) security and safeguarding client
information, the nurse observes a colleague going home with printed copies of client information
in a uniform jacket. Which action should the nurse take?
A) File a detailed incident report with the specific hiring facility.
B) Warn the colleague that their actions are unprofessional.
C) Comment anonymously about the action on a staff discussion board.
D) Communicate the colleague's actions to the unit charge nurse. - ANSA) File a detailed
incident report with the specific hiring facility.
The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease
implemented in a rural health clinic. Which outcome indicates the program is effective?
A) At-risk clients received an increased number of routine health screenings.
B) Clients reported having new confidence in making healthy food choices.
C) Clients who incurred disease complications promptly received rehabilitation.
D) Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign. - ANSC)
Clients who incurred disease complications promptly received rehabilitation.
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the
wound. before reporting this finding to the healthcare provider, the nurse should review which of
the client's laboratory values?
A) Culture for sensitive organisms.
B) Serum blood glucose (BG) level.
C) Creatinine level.
D) Serum albumin. - ANSA) Culture for sensitive organisms.
A client is admitted with acute pancreatitis. the client admits to drinking a pint of bourbon daily.
The nurse medicates the client for pain and monitors vital signs every 2 hours. Which finding
should the nurse report immediately to the healthcare provider?
A) Anorexia and abdominal distention.
B) Abdominal pain and vomiting.
C) Confusion and tremors.
D) Yellowing and itching of skin. - ANSC) Confusion and tremors.
A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count
of 25,000/mm^3 (25 x 10^9/L). Which intervention is most important for the nurse to include in
this client's plan of care?
A) Assess urine and stool for occult blood.
B) Monitor for signs of activity intolerance.
