Hesi exit 5 - 160 Questions
Suicide precautions are initiated for a child admitted to the mental health unit following an
intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in
the client's room. Which intervention is most important for the nurse to implement? -
ANSRemove cigarettes for the client's room
A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice
care. What information should the nurse provide? (Select all that apply.)
A.)A client must be willing to accept palliative care, not curative care.
B.)The healthcare provider must project that the client has 6 months or less to live.
C.)The client must be diagnosed with clinical depression
D.)The client must be of sound mind - ANSA,B
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should
the nurse include in this client's teaching plan? - ANSAvoid use of nonsteroidal ant-inflammatory
drugs (NSAID).
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and
diaphoretic with jugular vein distention. Which prescription should the nurse administer first? -
ANSDigoxin
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and
an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the
RN? - ANSSupervise a newly hired graduate nurse during an admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client
stares into the distance and appears to be concentrating on something other than the lesson the
nurse is presenting. What action should the nurse take? - ANSAsk the client what he is thinking
about at his time.
After several hours of non-productive coughing, a client presents to the emergency room
complaining of chest tightness and shortness of breath. History includes end stage chronic
obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary
assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should
the nurse implement? (Select all that apply.)
A.)Administer PRN nebulizer treatment.
,B.)Obtain 12 lead electrocardiogram.
C.)Monitor continuous oxygen saturation.
D.) Lay the client in the prone position - ANSA,B,C
The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is
restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should
the nurse take? - ANSAdminister a prescribed analgesia for pain.
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol
that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should
the nurse provide the parents about caring for their child? - ANSUse sunblock or protective
clothing when outdoors.
Two days after admission a male client remembers that he is allergic to eggs, and informs the
nurse of the allergy. Which actions should the nurse implement? SATA
A.) Tell the client that its a mild reaction
B.)Notify the food services department of the allergy.
C.)Enter the allergy information in the client's record.
D.)Add egg allergy to the client's allergy arm band. - ANSB,C,D
The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of
continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so
the healthcare provider performs a successful oral, intubation. What action should the nurse
implement? - ANSPerform bilateral chest auscultation.
After administering an antipyretic medication. Which intervention should the nurse implement? -
ANSEncouraging liberal fluid intake
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation
should be included in preparing this client for this treatment? - ANSDescribe radioactive iodine
as a tasteless, colorless medication administered by the healthcare provider
After a colon resection for colon cancer, a male client is moaning while being transferred to the
Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? -
ANSDetermine client's pulse, blood pressure, and respirations
, The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and
an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse
delegate to the UAP? (Select all that apply)
A.)Take postoperative vital signs for a client who has an epidual following knee arthroplasty
B.)Collect a sputum specimen for a client with a fever of unknown origin
C.)Ambulate a client who had a femoral-popliteal bypass graft yesterday - ANSA,B,C
A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi
Fowler position with his arms at his side. What action should the nurse implement? - ANSRaise
the head of the bed to a Fowler's position and support his arms with a pillow
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has
difficulty describing the exact nature and location of the pain to the nurse. Which action should
the nurse implement next? - ANSAdminister the analgesic as requested
The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid
replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who
weighs 76kg. How many ml should the client receive? (Enter numeric value only.) - ANS12160
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate
the client has thrombocytopenia. Based on this data, which nursing assessment is most
important following the procedure?
A.)Observe aspiration site.
B.)Assess body temperature
C.)Monitor skin elasticity
D.)Measure urinary output - ANSA
An 18-year-old female client is seen at the health department for treatment of condylomata
acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention
should the nurse implement? - ANSReinforce the importance of annual papanicolaou (Pap)
smears.
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during
the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse
implement first? - ANSEstablish a structured routine for the client to follow.
Suicide precautions are initiated for a child admitted to the mental health unit following an
intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in
the client's room. Which intervention is most important for the nurse to implement? -
ANSRemove cigarettes for the client's room
A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice
care. What information should the nurse provide? (Select all that apply.)
A.)A client must be willing to accept palliative care, not curative care.
B.)The healthcare provider must project that the client has 6 months or less to live.
C.)The client must be diagnosed with clinical depression
D.)The client must be of sound mind - ANSA,B
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should
the nurse include in this client's teaching plan? - ANSAvoid use of nonsteroidal ant-inflammatory
drugs (NSAID).
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and
diaphoretic with jugular vein distention. Which prescription should the nurse administer first? -
ANSDigoxin
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and
an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the
RN? - ANSSupervise a newly hired graduate nurse during an admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client
stares into the distance and appears to be concentrating on something other than the lesson the
nurse is presenting. What action should the nurse take? - ANSAsk the client what he is thinking
about at his time.
After several hours of non-productive coughing, a client presents to the emergency room
complaining of chest tightness and shortness of breath. History includes end stage chronic
obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary
assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should
the nurse implement? (Select all that apply.)
A.)Administer PRN nebulizer treatment.
,B.)Obtain 12 lead electrocardiogram.
C.)Monitor continuous oxygen saturation.
D.) Lay the client in the prone position - ANSA,B,C
The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is
restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should
the nurse take? - ANSAdminister a prescribed analgesia for pain.
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol
that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should
the nurse provide the parents about caring for their child? - ANSUse sunblock or protective
clothing when outdoors.
Two days after admission a male client remembers that he is allergic to eggs, and informs the
nurse of the allergy. Which actions should the nurse implement? SATA
A.) Tell the client that its a mild reaction
B.)Notify the food services department of the allergy.
C.)Enter the allergy information in the client's record.
D.)Add egg allergy to the client's allergy arm band. - ANSB,C,D
The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of
continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so
the healthcare provider performs a successful oral, intubation. What action should the nurse
implement? - ANSPerform bilateral chest auscultation.
After administering an antipyretic medication. Which intervention should the nurse implement? -
ANSEncouraging liberal fluid intake
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation
should be included in preparing this client for this treatment? - ANSDescribe radioactive iodine
as a tasteless, colorless medication administered by the healthcare provider
After a colon resection for colon cancer, a male client is moaning while being transferred to the
Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? -
ANSDetermine client's pulse, blood pressure, and respirations
, The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and
an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse
delegate to the UAP? (Select all that apply)
A.)Take postoperative vital signs for a client who has an epidual following knee arthroplasty
B.)Collect a sputum specimen for a client with a fever of unknown origin
C.)Ambulate a client who had a femoral-popliteal bypass graft yesterday - ANSA,B,C
A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi
Fowler position with his arms at his side. What action should the nurse implement? - ANSRaise
the head of the bed to a Fowler's position and support his arms with a pillow
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has
difficulty describing the exact nature and location of the pain to the nurse. Which action should
the nurse implement next? - ANSAdminister the analgesic as requested
The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid
replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who
weighs 76kg. How many ml should the client receive? (Enter numeric value only.) - ANS12160
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate
the client has thrombocytopenia. Based on this data, which nursing assessment is most
important following the procedure?
A.)Observe aspiration site.
B.)Assess body temperature
C.)Monitor skin elasticity
D.)Measure urinary output - ANSA
An 18-year-old female client is seen at the health department for treatment of condylomata
acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention
should the nurse implement? - ANSReinforce the importance of annual papanicolaou (Pap)
smears.
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during
the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse
implement first? - ANSEstablish a structured routine for the client to follow.
