HESI 799 RN Exit Exam 2024 Questions And Correct Answers

HESI 799 RN Exit Exam 2024 Questions And Correct Answers The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? a. High salt can damage the lining of the blood vessels b. Too much salt can cause the kidneys to retain fluid c. Excessive salt can cause blood vessels to constrict d. Salt can cause information inside the blood vessels - ANSWER b. Too much salt can cause the kidneys to retain fluid Rationale: Excessive salt intake can contribute to primary hypertension by causing renal salt retention which influence water retention that expands blood volume and pressure (ACD) are not believed to contribute to primary hypertension. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image). right upper chest, left midaxillary - ANSWER right upper chest, left midaxillary In assessing a pressure ulcer on a client's hip, which action should the nurse include? a. Determine the degree of elasticity surrounding the lesion b. Photograph the lesion with a ruler placed next to the lesion c. Stage the depth of the ulcer using the Braden numeric scale d. Use a gloved finger to palpate for tunneling around the lesion - ANSWER b. Photograph the lesion with a ruler placed next to the lesion Rationale: An ulcer extends into the dermis or subcutaneous tissue and is likely to increase in size and depth, so assessment should include photograph with measuring device to document the size of the lesion. A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care? a. Implements decisions about future hospices services within the next 3 months. b. Maintaining pain level below 4 when implementing outpatient pain clinic strategies. c. Request home health care if independence become compromised for 5 days. d. Arranges for short term counseling stressors impact work schedule for 2 weeks. - ANSWER b. Maintaining pain level below 4 when implementing outpatient pain clinic strategies. Rationale: An outpatient pain clinic provides the interdisciplinary services needed to manage chronic pain. Also, the client has a terminal disease and is being discharge home, hospice and health care are not indicating currently. Short term counseling is not an option. A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement? a. Auscultate all quadrants of the abdomen. b. Perform a digital rectal exam c. Palpate the liver and spleen d. Obtain a hemoccult of the client's stool - ANSWER a. Auscultate all quadrants of the abdomen. The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating? a. A paced rhythm with 100% capture after pacemaker replacement b. Normal sinus rhythm and complaining of chest pain c. Atrial fibrillation with congestive heart failure and complaining of fatigue d. Sinus tachycardia 3 days after a myocardial infarction - ANSWER b. Normal sinus rhythm and complaining of chest pain The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective? a. These warts are caused by a fungus b. Early treatment is very effective c. I need to have regular pap smears d. I will clean my hot tub better - ANSWER c. I need to have regular pap smears While the nurse is conducting a daily assessment of an older woman who resides in a long-term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first? a. Ask the client when a family member last visited her. b. Determine the client's orientation to time and space c. Review the client's record regarding social interactions d. Reassure the client of her family's love for her - ANSWER a. Ask the client when a family member last visited her. A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? a. creatinine clearance 25 mL/ minute b. calcium 9 mg/dl c. hemoglobin 12 grams/dl d. partial thromboplastin time (PTT) 30 seconds - ANSWER a. creatinine clearance 25 mL/ minute The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement? a. Observe the wound for dehiscence b. Teach the client to splint the incision while coughing c. Assess the skin surrounding the wound for maceration d. Obtain a culture of the wound drainage. - ANSWER a. Observe the wound for dehiscence A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status? a. A 24-hour diet history b. History of a recent weight loss c. Status of current petite d. Condition of hair, nails, and skin - ANSWER d. Condition of hair, nails, and skin Rationale: The assessment of hair, nails and skin is most indicative of long-term nutritional status, which is important in the healing process. The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention? a. A young adult with Crohn's disease who reports having diarrheal stools b. An older adult with type 2 diabetes whose breakfast tray arrives 20 minutes late. c. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping. d. A teenager who reports continued pain 30 minutes after receiving an oral analgesic. - ANSWER c. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping Rationale: The nurse should immediately assess the child whose infusion pump is alarming during chemotherapy administration because infiltration of a caustic agent can cause tissue damage and children are at greater risk for fluid volume imbalance. Diarrhea is a common occurrence for Crohn's disease. Late consumption of food for a diabetic is of concern, but 20 minutes late is usually not life-threatening. Treatment of pain is most important but has been only 30 mints since the client was medicated and this issue can be assessed in 10 mints or delegated to another nurse. The nurse is preparing to administer an infusion of amino acid dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first? a. Attached de IV tubing to the central line. b. Check the TPN solution for cloudiness c. Set the infusion PUMP at the prescribed rate. d. Prime the IV tubing with the TPN solution. - ANSWER b. Check the TPN solution for cloudiness On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take? a. Encourage the nurse purchase the reading glasses in the hospital gift shop b. Request another nurse to assist the staff nurse with her documentation c. Ask the nurse to return home and get her prescription eyeglasses for work. d. Tell the staff nurse to take a day off and change her weekly work schedule. - ANSWER c. Ask the nurse to return home and get her prescription eyeglasses for work A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the client's prescribed medications? a. Clopidogrel (Plavix), an antiplatelet agent, given orally b. Methylprednisolone (solu-medrol), a corticosteroid, to be given IV c. Nitroglycerin (Nitro-Dur) an antianginal, to be given transdermally. d. Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous. e. Furosemide (Lasix), a loop diuretic, to be given intravenously. - ANSWER a. Clopidogrel (Plavix), an antiplatelet agent, given orally Rationale: Because of the emesis is coffee brown appearance, which is an indicator of bleeding in GI tract, the nurse should consult the health care provider because increase the risk of bleeding. A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit? 1. Discuss the importance of continuing the usual at-home activities 2. Encourage the family to plan daily activities to keep the client busy 3. Have friends and family visit the client at a welcome party. 4. Instruct family to monitor the client's choice of television programs. - ANSWER 1. Discuss the importance of continuing the usual at-home activities Rationale: Week-end pass are schedules to help the client ease back into the family's routine, so the client can back to normal activities. When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first? a. Include the family in client's care b. Request the chaplain's presence c. Ask the family to identify a specific spokesperson d. Page the healthcare provider to speak with family. - ANSWER c. Ask the family to identify a specific spokesperson A client with pneumonia has an IV of lactated ringer's solution infusing at 30ml/hr current labor....sodium level of 155 mEq/L, a serum potassium level of 4mEq/L.... what nursing intervention is most important? a. Provide a high-potassium snack, such as bananas. b. Obtain a prescription to increase the IV rate c. Administer the next scheduled dose of antibiotic d. Review the report of the most recent chest x-ray. - ANSWER b. Obtain a prescription to increase the IV rate After teaching a male client with chronic kidney disease (CKD) about therapeutic diet... which menu of foods indicates that the teaching was effective? Select all that apply a- A slice of whole grain toast b- Half cup of black beans c- A ham and cheese sandwich d- A bowl of cream of wheat e- Two bananas. - ANSWER a- A slice of whole grain toast d- A bowl of cream of wheat Rationale: Patient with CKD have elevated serum potassium, sodium and protein levels. A and D are low in potassium, sodium and protein, Beans are rich in proteins. C are high in sodium and potassium and E are rich in potassium. A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM? a- Immune antibodies attack pancreatic beta cells resulting in no insulin b- The body cells develop resistance to the action of insulin. c- Body organs produce less insulin and more glucagon d- The liver produces excess glucose in response to excess glycotrophic hormones - ANSWER d. The body cells develop resistance to the action of insulin An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse .... The client provides the nurse with a living will and DNR. What action should the nurse implement? a- Inform the family of the client's wishes b- Obtain a prescription for DNR c- Clergy consultation d- Ask the patient why he made this choice - ANSWER b. Obtain a prescription for DNR A client whose wrists are sutured from a recent suicide attempt has been transferred from a medical unit. Which nursing diagnosis is of the highest priority? a- Risk for self-directed violence related to impulsive actions b- Risk for violence related to feeling of guilt and failure c- Low self-esteem related to feeling of loss of control d- Ineffective coping related to violent actions towards self. - ANSWER a. Risk for self-directed violence related to impulsive actions During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement? a- Instruct the client to keep the left leg straight b- Keep the head of bed at 60-degree angle. c- Observe the insertion site for a hematoma d- Manually flush the arterial sheath hourly e- Circle first noted drainage on the dressing - ANSWER a- Instruct the client to keep the left leg straight c- Observe the insertion site for a hematoma e- Circle first noted drainage on the dressing One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement? a- Encourage use of analgesics before position change b- Assess anxiety about transferring to commode chair c- Assist client during transfer on the first two days d- Review use of assistive devices for weight bearing. - ANSWER Encourage use of analgesics before position change The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms? a- Fruity breath odor b- Polyphagia c- Diaphoresis d- Polydipsia - ANSWER c. Diaphoresis A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take? a- Contact the regional organ procurement agency b- Convene a multidisciplinary care conference c- Explain that client may not be an organ donor candidate d- Discontinue feeding and fluids per the family's request. - ANSWER a. Contact the regional organ procurement agency A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? A) "I understand that a glass of wine with dinner is healthy. "B) "Beer is not really hard alcohol, so I guess I can drink some. "C) "If I drink, my baby may be harmed before I know I am pregnant. " D) "Drinking with meals reduces the effects of alcohol." - ANSWER "C) "If I drink, my baby may be harmed before I know I am pregnant. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output - ANSWER C) Loss of pulse in the extremity A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago.He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede' the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again - ANSWER C) Assist him to stand by the side of the bed to void The nurse is caring for a client who requires a mechanical ventilator for breathing.The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator - ANSWER B) Perform a quick assessment of the client's condition The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? A) "I can't lie in 1 position for more than thirty minutes. "B) "I am allergic to shrimp." C) "I suffer from claustrophobia. "D) "I developed a severe headache after a spinal tap." - ANSWER "B) "I am allergic to shrimp." The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube - ANSWER A) Hold the tube feeding and notify the provider To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion - ANSWER A) Apply suction for no more than 10 seconds An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) Administer the medication in 2 separate injections B) Give the medication in the dorsal gluteal site C) Call to get a smaller volume ordered D) Check with pharmacy for a liquid form of the medication skip - ANSWER A) Administer the medication in 2 separate injections The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) Enhance absorption of the medication B) Ensure that the entire dose of medication is given C) Provide more even distribution of the drug D) Prevent the drug from tissue irritation Skip - ANSWER D) Prevent the drug from tissue irritation Skip A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) Diaphoresis with decreased urinary output B) Increased heart rate with increase respirations C) Improved respiratory status and increased urinary output D) Decreased chest pain and decreased blood pressure - ANSWER C) Improved respiratory status and increased urinary output