HESI 799 RN Exit Exam (301-400) Questions & Answers

A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement? a. Overlook the client's behavior. b. Distract client to interfere with the ritual. c. Ask why the client checks the pulse. d. Hold client's hand to stop the behavior. - ANSWERSOverlook the client's behavior. A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which instructions should the nurse include? a. Wash hands before cleaning exit site b. Keep the head of the bed flat at night c. Feel for a thrill and a distal pulse nightly d. Do not get up if fluid is left in the abdomen - ANSWERSWash hands before cleaning exit site Rationale: meticulous hand hygiene is essential when performing care for a peritoneal dialysis, infections is a common complication of peritoneal dialysis. The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse? a- Opening the package b- Picking up the second glove c- Picking up the first glove d- Positioning of the table - ANSWERSPicking up the second glove A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? a. Altered consciousness within the first 24 hours after injury. b. Cushing reflex and cerebral edema after 24 hours c. Fever, nuchal rigidity and opisthotonos within hours d. Headache and pupillary changes 48 hours after a head injury - ANSWERSAltered consciousness within the first 24 hours after injury. A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition? a. Pulmonary hypertension b. Left ventricular hypertrophy c. Renal failure d. Stroke - ANSWERSStroke The nurse ask the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement? a. Examine the genitalia as the last part of the total exam. b. Use soothing statements to facilitate cooperation c. Allow the child to keep underpants on to examine genitalia d. Work slowly and methodically so not to stress the child - ANSWERSExamine the genitalia as the last part of the total exam. Rationale: Examination of a child's genitalia is particularly stressful to toddles, so this assessment is best left as the last part of the examination. B are best done by a parent, not the nurse. The genitals must be completely visualized and sometimes palpates underwear for a brief period of. The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is _____. Which action should the nurse take to ensure adequate filling of the drip chamber? a. Lower the IV bag to a flat surface b. Compress the drip chamber c. Open the roller clamp d. Squeeze the bag of IV solution - ANSWERSCompress the drip chamber During an Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar syndrome in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? a. Urine ketones b. Urine albumin c. Serum protein d. Serum potassium - ANSWERSd. Serum potassium Rationale: Electrolyte shifts are common during correction of hyperosmolar and hyperglycemic states. Monitor electrolyte levels at least every 4 hours, or every 2 hours if needed. Monitor serum sodium and potassium levels closely. If needed, use isotonic and hypotonic saline solutions to adjust the patient's sodium level. Despite major potassium loss during diuresis in early HHS stages, many patients initially present in a hyperkalemic state due to dehydration. When fluid and insulin therapy begin, the serum potassium level may drop dramatically. In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis? a. Infectious process b. Metastatic process c. Autoimmune disorder d. Inflammatory disorder - ANSWERSinfectious process A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution? a. 0.9% sodium chloride solution (normal saline) b. 0.45% sodium chloride solution (half normal saline) c. 10% Dextrose in 0.45% sodium chloride d. 5% dextrose in 0.2% sodium chloride - ANSWERS0.9% sodium chloride solution (normal saline) Rationale: Normal range = 135-145 A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective? a. The nurse note that no pills remain in the prescription bottle. b. The client serum Depakote level is 125 mcg/ml c. The family reports a great reduction in client's maniac behavior d. The client denies any occurrence of suicidal ideation. - ANSWERSThe family reports a great reduction in client's maniac behavior The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately? a. headache, photophobia, and nuchal rigidity b. high fever, skin rash, and a productive cough c. nausea, vomiting, and poor skin turgor d. malaise, fever, and stiff, swollen joints - ANSWERSheadache, photophobia, and nuchal rigidity Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal infection, so this client should immediately be referred to the health care provider. AC D do not have priority of B A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse? a. Urinary incontinence b. Left forearm hematoma c. Disorientation to surroundings d. Dislodge intravenous site - ANSWERSLeft forearm hematoma Rationale: The left forearm hematoma may be indicative an injury, such as broken bone, that requires immediate intervention. A may be likely be due to the inability to use the toilet due to the fall. Disorientation is a common symptom of Alzheimer's disease. IV Dislodged is not an urgent concern. An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? a. Rebound abdominal tenderness b. nausea and projectile vomiting c. rib pain with deep inspiration d. diminished bilateral breath sounds - ANSWERSb. nausea and projectile vomiting Rationale: Projective vomiting is indicative of increasing intracranial pressure, which can lead to ischemic brain damage or death, so this finding warrants immediate intervention. Rebound abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to pain. Rib pain with inspiration may indicate rib fracture. The nurse has received funding to design a health promotion project for AfricanAmerican women who are at risk for developing breast cancer. Which resource is most important in designing this program? a. A listing of African-American women so live in the community b. Participation of community leaders in planning the program c. Morbidity data for breast cancer in women of all races d. Technical assistance to produce a video on breast self-examination. - ANSWERSParticipation of community leaders in planning the program After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? a. Initiate intravenous fluid as prescribed b. Notify the HCP of the need to reposition the catheter c. Remove the catheter and apply direct pressure for 5 minutes. d. Secure the catheter using aseptic technique - ANSWERSInitiate intravenous fluid as prescribed Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous fluid can be started. A and B are not indicated at this time. The catheter should be secure immediate following insertion (C) A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? a. The client has asymmetrical chest wall expansion b. The clients complain of pain at the insertion site c. The client chest's x-ray indicates decreased pleural effusion d. The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26 - ANSWERSa. The client has asymmetrical chest wall expansion Rationale: A potential complication of thoracentesis is a pneumothorax. The symptoms of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the local anesthetic effects "wear off" B is a desired result of thoracentesis and C is within normal limits. The home care nurse provide self-care instruction for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply a. Avoid prolonged standing or sitting b. Use a recliner for long periods of sitting c. Continue wearing elastic stockings d. Maintain the bed flat while sleeping e. Cross legs at knee but not at ankle - ANSWERSa. Avoid prolonged standing or sitting b. Use a recliner for long periods of sitting c. Continue wearing elastic stockings