Hesi 2 RN Exit Exam V2 160 Questions & Answers

1. A primipara with a breech presentation is in the transition phase pf labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client? - Supine with the foot of the bed raised 2. The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. what is the priority expected outcome for these classes? - Participants can identify at least three coping strategies to use during labor 3. Clinical portfolios are being introduced into the performance apprasial process for the nurses employed at the hospital. What should the nurse-manager request that each staff nurse include in the portfolio? - A self evaluation that identifies how the nurse has met professional objectives and goals 4. a work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to besot effective in developing the new care map? - Multisicipilinary group 5. An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? - Stage 3 6. When meeting with the client and the family, which nursing intervention demonstrates the nurses role as collaborator of care? - Coordinating and educating about multidisciplinary services 7. A low potassium diet is prescribed for a client what foods should the nurse try to avoid? - Dried prunes 8. A client is admitted with a medical diagnosis of addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? - Hypotension, rapid weak pulse, and rapid respiratory rate 9. The nurse plans to suction a male client. Who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse osculates rattling in the lungs. What safety factors should the nurse consider when suctioning this client? - Use a soft tip rubber suction catheter and avoid deep vigorous suctioning. 10. The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? The nurse is caring for critically ill clients. Which should be monitored for the development of neutogenic shock? A client with? - Spinal Cord injury 11. Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? - You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it? 12. The nurse is teaching staff in a long term - facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension? - Frequent blood pressure checks, including readings taken automated machines are recommended 13. A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? - Monitor for increased blood pressure and pulse 14. A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat diet, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. what intervention should the nurse implement? - Confront the client about the consequences of the behavior 15. A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate action by the nurse can lessen the symptoms of this " TET" spell? - Place child in kneechest position This pressure reduces the rush of blood flow through the septal hole and improves blood circulation. 16. A client with metastatic cancer is preparing to make a decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate? - It will identify someone that can make the decisions for you health care if you are ever in a coma or vegetative state 17.After eye drops are instilled, which instruction should the nurse provide to the client? - Close your eyelids 18. The nurse is preparing to administer IV fluid to a client with strict fluid restriction. IV tubing with which feature is most important for the nurse to select? - Burretrol Attachment 19. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states "My blood pressure is usually much lower." The nurse should tell the client to - go get a blood pressure check within the next 48 to 72 hours 20. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is - Manage pain 21. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? - An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 22. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? - "I understand the need to use those new skills." 23. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? - Gravida 3 para 1 24. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? - Gastric lavage PRN 25. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is - Verify correct placement of the tube 26. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to - Restore yin and yang 27. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? - thrombus formation 28. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? - the muscle 29. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? - Chlamydia 30. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member? - We have safety bars installed in the bathroom and have 24 hour alarms on the doors. 31. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? - Improve the client's nutrition status 32. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to - Force fluids and reassess blood pressure 33. Which individual is at greatest risk for developing hypertension? - 45 year-old African American attorney 34. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? - Tall peaked T waves 35. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication? - Decreased appetite 36. Which of these statements best describes the characteristic of an effective reward feedback system? - Specific feedback is given as close to the event as possible 37. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to - Progressive placental insufficiency 38. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? - Moist, productive cough 39. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test? - No special orders are necessary for this examination 40. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? - A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago 41. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? - A teenager who got a singed beard while camping 42. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? - Blood pressure 94/60 43. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is - establish an airway 44. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? - Notify the healthcare provider of the child's status 45. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first? - Have the client empty bladder 46. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? - bed wetting 47. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be takenby the nurse is to: - open the clients airway 48. A client has an orderfor 1000 ml of D5W over an 8 hour period. The nurse Discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? - auscultate the lungs 49. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? - 72 year-old recovering from surgery after a hip replacement 2 hours ago 50. A nurse observes a family member administer a rectalsuppository by having The client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? - That was done correctly. Did you have any problems with the insertion? 51. A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) Has died. Which type of precautions is the appropriate type to use when performing postmortem care? - contact precautions 52. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? - clean the meatus, begin voiding, then catch urine stream 53. The provider orders Lanoxin (digoxin) 0.125 mg POand furosomide 40mg Every day. Which of these foods would the nurse reinforce for the client to eat atleast daily? - watermelon 54. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? - Immediately wash the hands with vigor 55. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? - Walk up and whisper in the student's ear "Stop. Aspirate. Then inject." The med 56. A client with Guillain Barre is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? - Glascow Coma Scale 8, respirations regular 57. A client enters the emergency department unconscious via ambulance from the client's work place. What document should be given priority to guide the direction of care for this client? - A notarized original of advance directives brought in by the partner 58. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? - An admission at the change of shifts with atrial fibrillation and heart failure - PN 59. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? - Restlessness and increased mucus production 60. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? - "Clothes are becoming tighter across her abdomen." 61. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? - Proceed with the triage process in the same manner as any adult client 62. A newly admitted elderly client is severely dehydrated. When planning care for This client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? - Report hourly outputs of less than 30 ml/hr 63. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? - Strep throat went through all the children at the day care last month.