HESI VERSION3 EXIT EXAM WITH QUESTIONS AND
100% VERIFIED ANSWERS. [GRADED A+].
NEW UPDATE.
the nurse observes An unlicensed assistive Personnel applying and alcohol-based
hand rub while leaving a client's room after taking vital signs. Which action
should the nurse take ? - ANS✔✔-Remind the UAP to continue rubbing the hands
together until they are dry
The nurse is reviewing the possible complications that can occur for an infant of
a diabetic mother. Choose the most likely options for the information missing
from the statement(s) by selecting from the lists of options provided. - ANS✔✔-
The nurse recognizes that the infant of a diabetic mother is at risk for
hyperbilirubinemia, respiratory distress syndrome, and cardiomyopathy
Glucose level immediately after birth and then at 30 min, 1 hour, 2 hours, 4
hours, 8 and 12 hours and if symptoms suggest hypoglycemla.
• Breastfeed Immediately once stable, then on
demand. If unstable, may feed breast milk via
orogastric tube.
• If two feeding attempts fall to increase the
glucose levels or if symptoms of hypoglycemia
develop, apply dextrose (sugar) gel Inside the
baby's cheek.
• If the above are ineffective, IV glucose should
be administered to maintain glucose levels
above 45 mg/dL (2.5 mmol/L). - ANS✔✔-Monitor for Respiratory distress,
contact respiratory therapy for ABG and oxygen therapy, blood glucose level,
keep in warmer with Bilirubin lights, monitor temperature every 30 minutes,
feed immediately
,The nurse is reviewing lab work and nurses' notes to determine which actions to
take at this time. Which actions are appropriate for the nurse to take at this
time? Select all that apply. - ANS✔✔-A Keep infant In warmer with bilirubin lights
to maintain temperature of 97.6°
B Inform the mother that the baby is stable enough to take out of the warmer
D Explain to the mother that the baby's respiratory rate needs to be below 60 1
E Observe for signs of respiratory distress and monitor oxygenation by pulse c
Day 1
1800: The client Is a female neonate born at 37 weeks of gestation to a G 2 P 1
mother, who was diagnosed with gestational dlabetes. Following a spontaneous
vaginal birth, she received Apgar scores of 7 at 1 min and 8 at 5 min. The client
weighs 4036.97 g (8 Ibs. 9 oz) and appears pink with acrocyanosis and a
moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30
min of age. Axillary temperature 96° F (35.6° C), pulse 140, respiratory rate 80.
Blood glucose 35 mg/dL (1.9 mmol/L), bilirubin level 7 mg/dL (119.73 umol/L).
Fontanelles soft, Mongolian spot noted on lower back, Ballard maturity rating 37
weeks. - ANS✔✔-Proactive lactation management, strategies, support, and
follow-up for late-preterm infants and some early term infants are important
components that affect breastfeeding success. Prophylactic phototherapy is often
used in preterm infants to prevent a significant increase in serum bilirubin levels.
It is also recommended that healthy late-preterm and term infants (23S weeks
of gestation) receive follow-up care and assessment of bilirubin within 3 days of
discharge. Late preterm infants of a diabetic mother need to be monitored more
closely. Parents are taught to evaluate the number of voids and evidence of
adequate breastfeeding after the infant is home. Notify the primary care
practitioner if there are indications the infant is not feeding well, is difficult to
arouse for feedings, or is not voiding and stooling adequately. Seeing the
obstetrician at 8 weeks is contraindicated, as most postpartum visits are
between 4 and 6 wecks. ACOG recommends that postpartum care be an ongoing
process in which each woman's individual needs determine the services and
support she receives. Early follow-up is warranted for women who experienced
complications such as hypertensive disorders of pregnancy, those with chronic
health conditions, women at high risk for depression, and breastfeeding mothers
who are experiencing feeding problems,
Click to highlight the notes that demonstrate a positive outcome.
Day 2
0630: Vitals have remained stable throughout the night. Oxygen 98% on nasal
canal. Mother to breastfeed in nursery on demand. Able to tolerate breastmilk.
, Glucose after feeding was 60 mg/dL (3.3 mmol/L), temp 97.8° F (36.6° C) when
returned to warmer and Bili light. Chest x-ray and echocardiogram results were
normal. Calcium and magnesium within normal llmits, Direct bilirubin 5 mg/dI(5
umol/L), Discharge teaching Initlated, with goal of discharging infant and mother
on day 3. - ANS✔✔-Studies confirm the importance of maintaining serum
glucose levels above 45 mg/dL (25 mmol/1) in hyper insulinemic infants with
hypoglycemia to prevent serious neurologic sequel. Blood glucose levels continue
to improve. Direct bilirubin improved. Other signs of improvement include a
normal temperature for at least 8 hours, improved respiratory status with no
signs of respiratory distress syndrome and feedings are well tolerated.
when conducting an admission assessment, the nurse notes that an adult female
client has developed to new allergies since her last admission. The client
describes herself as lactose intolerance and states that she is unable to eat eggs.
Which interventions should the nurse implement? Select all that apply - ANS✔✔-
Add egg allergy to dient's identification arm band.
Atth dento describe her reaction to milk and eggs
Enter new allergy Inform at on In the clients electronic medical record
notify the dietary department of the client egg tolerance
The nurses preparing a dose of 60 MCG of Leriparatide. The medication is
labelled 750 MCG/2 .4 ML. how many ML should the nurse administer enter
numerical value only if rounding is required, round to the nearest 10th. -
ANS✔✔-0.2
The nurse on a pediatric unit observes a distraught mother in the hallway
scolding her three-year-old son for beating his fans. What in shell action should
the nurse take? - ANS✔✔-Provide disposable training parents while calming the
mother
100% VERIFIED ANSWERS. [GRADED A+].
NEW UPDATE.
the nurse observes An unlicensed assistive Personnel applying and alcohol-based
hand rub while leaving a client's room after taking vital signs. Which action
should the nurse take ? - ANS✔✔-Remind the UAP to continue rubbing the hands
together until they are dry
The nurse is reviewing the possible complications that can occur for an infant of
a diabetic mother. Choose the most likely options for the information missing
from the statement(s) by selecting from the lists of options provided. - ANS✔✔-
The nurse recognizes that the infant of a diabetic mother is at risk for
hyperbilirubinemia, respiratory distress syndrome, and cardiomyopathy
Glucose level immediately after birth and then at 30 min, 1 hour, 2 hours, 4
hours, 8 and 12 hours and if symptoms suggest hypoglycemla.
• Breastfeed Immediately once stable, then on
demand. If unstable, may feed breast milk via
orogastric tube.
• If two feeding attempts fall to increase the
glucose levels or if symptoms of hypoglycemia
develop, apply dextrose (sugar) gel Inside the
baby's cheek.
• If the above are ineffective, IV glucose should
be administered to maintain glucose levels
above 45 mg/dL (2.5 mmol/L). - ANS✔✔-Monitor for Respiratory distress,
contact respiratory therapy for ABG and oxygen therapy, blood glucose level,
keep in warmer with Bilirubin lights, monitor temperature every 30 minutes,
feed immediately
,The nurse is reviewing lab work and nurses' notes to determine which actions to
take at this time. Which actions are appropriate for the nurse to take at this
time? Select all that apply. - ANS✔✔-A Keep infant In warmer with bilirubin lights
to maintain temperature of 97.6°
B Inform the mother that the baby is stable enough to take out of the warmer
D Explain to the mother that the baby's respiratory rate needs to be below 60 1
E Observe for signs of respiratory distress and monitor oxygenation by pulse c
Day 1
1800: The client Is a female neonate born at 37 weeks of gestation to a G 2 P 1
mother, who was diagnosed with gestational dlabetes. Following a spontaneous
vaginal birth, she received Apgar scores of 7 at 1 min and 8 at 5 min. The client
weighs 4036.97 g (8 Ibs. 9 oz) and appears pink with acrocyanosis and a
moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30
min of age. Axillary temperature 96° F (35.6° C), pulse 140, respiratory rate 80.
Blood glucose 35 mg/dL (1.9 mmol/L), bilirubin level 7 mg/dL (119.73 umol/L).
Fontanelles soft, Mongolian spot noted on lower back, Ballard maturity rating 37
weeks. - ANS✔✔-Proactive lactation management, strategies, support, and
follow-up for late-preterm infants and some early term infants are important
components that affect breastfeeding success. Prophylactic phototherapy is often
used in preterm infants to prevent a significant increase in serum bilirubin levels.
It is also recommended that healthy late-preterm and term infants (23S weeks
of gestation) receive follow-up care and assessment of bilirubin within 3 days of
discharge. Late preterm infants of a diabetic mother need to be monitored more
closely. Parents are taught to evaluate the number of voids and evidence of
adequate breastfeeding after the infant is home. Notify the primary care
practitioner if there are indications the infant is not feeding well, is difficult to
arouse for feedings, or is not voiding and stooling adequately. Seeing the
obstetrician at 8 weeks is contraindicated, as most postpartum visits are
between 4 and 6 wecks. ACOG recommends that postpartum care be an ongoing
process in which each woman's individual needs determine the services and
support she receives. Early follow-up is warranted for women who experienced
complications such as hypertensive disorders of pregnancy, those with chronic
health conditions, women at high risk for depression, and breastfeeding mothers
who are experiencing feeding problems,
Click to highlight the notes that demonstrate a positive outcome.
Day 2
0630: Vitals have remained stable throughout the night. Oxygen 98% on nasal
canal. Mother to breastfeed in nursery on demand. Able to tolerate breastmilk.
, Glucose after feeding was 60 mg/dL (3.3 mmol/L), temp 97.8° F (36.6° C) when
returned to warmer and Bili light. Chest x-ray and echocardiogram results were
normal. Calcium and magnesium within normal llmits, Direct bilirubin 5 mg/dI(5
umol/L), Discharge teaching Initlated, with goal of discharging infant and mother
on day 3. - ANS✔✔-Studies confirm the importance of maintaining serum
glucose levels above 45 mg/dL (25 mmol/1) in hyper insulinemic infants with
hypoglycemia to prevent serious neurologic sequel. Blood glucose levels continue
to improve. Direct bilirubin improved. Other signs of improvement include a
normal temperature for at least 8 hours, improved respiratory status with no
signs of respiratory distress syndrome and feedings are well tolerated.
when conducting an admission assessment, the nurse notes that an adult female
client has developed to new allergies since her last admission. The client
describes herself as lactose intolerance and states that she is unable to eat eggs.
Which interventions should the nurse implement? Select all that apply - ANS✔✔-
Add egg allergy to dient's identification arm band.
Atth dento describe her reaction to milk and eggs
Enter new allergy Inform at on In the clients electronic medical record
notify the dietary department of the client egg tolerance
The nurses preparing a dose of 60 MCG of Leriparatide. The medication is
labelled 750 MCG/2 .4 ML. how many ML should the nurse administer enter
numerical value only if rounding is required, round to the nearest 10th. -
ANS✔✔-0.2
The nurse on a pediatric unit observes a distraught mother in the hallway
scolding her three-year-old son for beating his fans. What in shell action should
the nurse take? - ANS✔✔-Provide disposable training parents while calming the
mother
