HESI 799 RN Exit Exam with correct
answers
A male client is admitted for the removal of an internal fixation that was
|| || || || || || || || || || || || ||
inserted for the fracture ankle. During the admission history, he tells the
|| || || || || || || || || || || ||
nurse he recently received vancomycin (vancomycin) for a methicillin-
|| || || || || || || || ||
resistant Staphylococcus aureus (MRSA) wound infection. Which action
|| || || || || || ||
should the nurse take? (Select all that apply.)
|| || || || || || || ||
a. Collect multiple site screening culture for MRSA
|| || || || || || ||
b. Call healthcare provider for a prescription for linezolid (Zyrovix)
|| || || || || || || || ||
c. Place the client on contact transmission precautions
|| || || || || || ||
d. Obtain sputum specimen for culture and sensitivity
|| || || || || || ||
e. Continue to monitor for client sign of infection. - 🔸🔶CORRECT ANSWERS
|| || || || || || || || || || ||
✔✔a. Collect multiple site screening culture for MRSA
|| || || || || || || ||
c. Place the client on contact transmission precautions
|| || || || || || ||
e. Continue to monitor for client sign of infection.
|| || || || || || || ||
Rationale: Until multi-site screening cultures come back negative (A), the
|| || || || || || || || ||
client should be maintained on contact isolation(C) to minimize the risk for
|| || || || || || || || || || || ||
nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infecting, is
|| || || || || || || || ||
not indicated, unless the client has an active skin structure infection cause by
|| || || || || || || || || || || || ||
MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A
|| || || || || || || || || ||
sputum culture is not indicated D) based on the client's history is a wound
|| || || || || || || || || || || || || ||
infection.
||
,A vacuum-assistive closure (VAC) device is being use to provide wound care
|| || || || || || || || || || ||
for a client who has stage III pressure ulcer on a below-the- knee (BKA)
|| || || || || || || || || || || || || ||
residual limb. Which intervention should the nurse implement to ensure
|| || || || || || || || || ||
maximum effectiveness of the device?
|| || || || ||
a. Empty the device every 8 hours and change the dressing daily ensure
|| || || || || || || || || || || ||
sterility
||
b. Extended the transparent film dressing only to edge of wound to prevent
|| || || || || || || || || || || ||
tension.
||
c. Ensure the transparent dressing has no tears that might create vacuum
|| || || || || || || || || || ||
leaks
||
d. Use an adhesive remover when changing the dressing to promote comfort. -
|| || || || || || || || || || || ||
🔸🔶CORRECT ANSWERS ✔✔Ensure the transparent dressing has no tears
|| || || || || || || || ||
that might create vacuum leak
|| || || || ||
Rationale: The nurse should ensure that the VAC transparent film is intact,
|| || || || || || || || || || ||
without tears or loose edges C) because a break in the seal resulting in
|| || || || || || || || || || || || || ||
drying the wound and decreasing the vacuum. The vacuum-assisted closure
|| || || || || || || || || ||
(VAC) device uses an open sponge in the wound bed, sealed with a
|| || || || || || || || || || || || ||
transparent film dressing and tube extrudes to a suction device that exert
|| || || || || || || || || || || ||
negative pressure to remove excess wound fluid, reduce the bacterial count
|| || || || || || || || || || ||
and stimulate granulation. The VAC is changed every other day or third day,
|| || || || || || || || || || || || ||
not (A) depending on the stage of wound healing and emptied when full or
|| || || || || || || || || || || || || ||
weekly. The transparent wound dressing should extend 3 to 5 cm beyond the
|| || || || || || || || || || || || ||
wound edges, not (B) to ensure and airtight seal. Adhesive removers leave a
|| || || || || || || || || || || || ||
reduce that binder transparent film adherence (D)
|| || || || || || ||
The nurse is developing the plan of care for a client with pneumonia and
|| || || || || || || || || || || || ||
includes the nursing diagnosis of "Ineffective airway clearance related to
|| || || || || || || || || ||
, thick pulmonary secretions." Which intervention is most important for the
|| || || || || || || || || ||
nurse to include in the client's plan of care?
|| || || || || || || || ||
a. Increase fluid intake to 3,000 ml/daily
|| || || || || ||
b. Administer O2 at 5L/mint per nasal cannula
|| || || || || || ||
c. Maintain the client in a semi Fowler's position
|| || || || || || || ||
d. Provide frequent rest period. - 🔸🔶CORRECT ANSWERS ✔✔Increase fluid
|| || || || || || || || ||
intake to 3,000 ml/daily
|| || || ||
Rationale: The plan of care should include an increase in fluid intake (A) to
|| || || || || || || || || || || || ||
liquefy and thin secretions for easier removal of thick pulmonary secretion
|| || || || || || || || || || ||
which facilitates airway clearance. (B) should be implemented for signs of
|| || || || || || || || || || ||
hypoxia (C) implemented to facilitate lung expansion, and (D) implemented
|| || || || || || || || || ||
for activity intolerance, but these interventions do not have the priority of
|| || || || || || || || || || || ||
(A)
||
The nurse plans to collect a 24- hour urine specimen for a creatinine
|| || || || || || || || || || || ||
clearance test. Which instruction should the nurse provide to the adult male
|| || || || || || || || || || || ||
client?
||
a. Clearance around the meatus, discard first portion of voiding, and collect
|| || || || || || || || || || ||
the rest in a sterile bottle
|| || || || || ||
b. Urinate at specific time, discard the urine, and collect all subsequent urine
|| || || || || || || || || || || ||
during the next 24 hours.
|| || || || ||
c. For the next 24 hours, notify the nurse when the bladder is full, and the
|| || || || || || || || || || || || || || ||
nurse will collect catheterized specimens.
|| || || || ||
d. Urinate immediately into a urinal, and the lab will collect specimen every 6
|| || || || || || || || || || || || ||
hours, for the next 24 hours. - 🔸🔶CORRECT ANSWERS ✔✔Urinate at
|| || || || || || || || || || ||
, specific time, discard the urine, and collect all subsequent urine during the
|| || || || || || || || || || || ||
next 24 hours.
|| || ||
Rationale: Urinate at specific time, discard the urine, and collect all
|| || || || || || || || || ||
subsequent urine during the next 24 hours is the correct procedure for
|| || || || || || || || || || || ||
collecting 24-hour urine specimen. Discarding even one voided specimen
|| || || || || || || || ||
invalidate the test.
|| || ||
The nurse is preparing to administer a histamine 2-receptor antagonist to a
|| || || || || || || || || || ||
client with peptic ulcer disease. What is the primary purpose of this drug
|| || || || || || || || || || || || ||
classification?
||
a. Neutralize hydrochloric (HCI) acid in the stomach
|| || || || || || ||
b. Decreases the amount of HCL secretion by the parietal cells in the stomach
|| || || || || || || || || || || || ||
c. Inhibit action of acetylcholine by blocking parasympathetic nerve endings.
|| || || || || || || || ||
d. Destroys microorganisms causing stomach inflammation. - 🔸🔶CORRECT
|| || || || || || ||
ANSWERS ✔✔Decreases the amount of HCL secretion by the parietal cells in
|| || || || || || || || || || || ||
the stomach
|| ||
Rationale: B correctly describe the action of histamine 2 receptor antagonist
|| || || || || || || || || ||
in helping to prevent peptic ulcer disease.
|| || || || || || ||
The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase
|| || || || || || ||
inhibitor, for a client with Type 2 diabetes mellitus. Which information
|| || || || || || || || || || ||
provides the best indicator of the drug's effectiveness?
|| || || || || || || ||
a. Body max index (BMI) between 20 and 24
|| || || || || || || ||
answers
A male client is admitted for the removal of an internal fixation that was
|| || || || || || || || || || || || ||
inserted for the fracture ankle. During the admission history, he tells the
|| || || || || || || || || || || ||
nurse he recently received vancomycin (vancomycin) for a methicillin-
|| || || || || || || || ||
resistant Staphylococcus aureus (MRSA) wound infection. Which action
|| || || || || || ||
should the nurse take? (Select all that apply.)
|| || || || || || || ||
a. Collect multiple site screening culture for MRSA
|| || || || || || ||
b. Call healthcare provider for a prescription for linezolid (Zyrovix)
|| || || || || || || || ||
c. Place the client on contact transmission precautions
|| || || || || || ||
d. Obtain sputum specimen for culture and sensitivity
|| || || || || || ||
e. Continue to monitor for client sign of infection. - 🔸🔶CORRECT ANSWERS
|| || || || || || || || || || ||
✔✔a. Collect multiple site screening culture for MRSA
|| || || || || || || ||
c. Place the client on contact transmission precautions
|| || || || || || ||
e. Continue to monitor for client sign of infection.
|| || || || || || || ||
Rationale: Until multi-site screening cultures come back negative (A), the
|| || || || || || || || ||
client should be maintained on contact isolation(C) to minimize the risk for
|| || || || || || || || || || || ||
nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infecting, is
|| || || || || || || || ||
not indicated, unless the client has an active skin structure infection cause by
|| || || || || || || || || || || || ||
MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A
|| || || || || || || || || ||
sputum culture is not indicated D) based on the client's history is a wound
|| || || || || || || || || || || || || ||
infection.
||
,A vacuum-assistive closure (VAC) device is being use to provide wound care
|| || || || || || || || || || ||
for a client who has stage III pressure ulcer on a below-the- knee (BKA)
|| || || || || || || || || || || || || ||
residual limb. Which intervention should the nurse implement to ensure
|| || || || || || || || || ||
maximum effectiveness of the device?
|| || || || ||
a. Empty the device every 8 hours and change the dressing daily ensure
|| || || || || || || || || || || ||
sterility
||
b. Extended the transparent film dressing only to edge of wound to prevent
|| || || || || || || || || || || ||
tension.
||
c. Ensure the transparent dressing has no tears that might create vacuum
|| || || || || || || || || || ||
leaks
||
d. Use an adhesive remover when changing the dressing to promote comfort. -
|| || || || || || || || || || || ||
🔸🔶CORRECT ANSWERS ✔✔Ensure the transparent dressing has no tears
|| || || || || || || || ||
that might create vacuum leak
|| || || || ||
Rationale: The nurse should ensure that the VAC transparent film is intact,
|| || || || || || || || || || ||
without tears or loose edges C) because a break in the seal resulting in
|| || || || || || || || || || || || || ||
drying the wound and decreasing the vacuum. The vacuum-assisted closure
|| || || || || || || || || ||
(VAC) device uses an open sponge in the wound bed, sealed with a
|| || || || || || || || || || || || ||
transparent film dressing and tube extrudes to a suction device that exert
|| || || || || || || || || || || ||
negative pressure to remove excess wound fluid, reduce the bacterial count
|| || || || || || || || || || ||
and stimulate granulation. The VAC is changed every other day or third day,
|| || || || || || || || || || || || ||
not (A) depending on the stage of wound healing and emptied when full or
|| || || || || || || || || || || || || ||
weekly. The transparent wound dressing should extend 3 to 5 cm beyond the
|| || || || || || || || || || || || ||
wound edges, not (B) to ensure and airtight seal. Adhesive removers leave a
|| || || || || || || || || || || || ||
reduce that binder transparent film adherence (D)
|| || || || || || ||
The nurse is developing the plan of care for a client with pneumonia and
|| || || || || || || || || || || || ||
includes the nursing diagnosis of "Ineffective airway clearance related to
|| || || || || || || || || ||
, thick pulmonary secretions." Which intervention is most important for the
|| || || || || || || || || ||
nurse to include in the client's plan of care?
|| || || || || || || || ||
a. Increase fluid intake to 3,000 ml/daily
|| || || || || ||
b. Administer O2 at 5L/mint per nasal cannula
|| || || || || || ||
c. Maintain the client in a semi Fowler's position
|| || || || || || || ||
d. Provide frequent rest period. - 🔸🔶CORRECT ANSWERS ✔✔Increase fluid
|| || || || || || || || ||
intake to 3,000 ml/daily
|| || || ||
Rationale: The plan of care should include an increase in fluid intake (A) to
|| || || || || || || || || || || || ||
liquefy and thin secretions for easier removal of thick pulmonary secretion
|| || || || || || || || || || ||
which facilitates airway clearance. (B) should be implemented for signs of
|| || || || || || || || || || ||
hypoxia (C) implemented to facilitate lung expansion, and (D) implemented
|| || || || || || || || || ||
for activity intolerance, but these interventions do not have the priority of
|| || || || || || || || || || || ||
(A)
||
The nurse plans to collect a 24- hour urine specimen for a creatinine
|| || || || || || || || || || || ||
clearance test. Which instruction should the nurse provide to the adult male
|| || || || || || || || || || || ||
client?
||
a. Clearance around the meatus, discard first portion of voiding, and collect
|| || || || || || || || || || ||
the rest in a sterile bottle
|| || || || || ||
b. Urinate at specific time, discard the urine, and collect all subsequent urine
|| || || || || || || || || || || ||
during the next 24 hours.
|| || || || ||
c. For the next 24 hours, notify the nurse when the bladder is full, and the
|| || || || || || || || || || || || || || ||
nurse will collect catheterized specimens.
|| || || || ||
d. Urinate immediately into a urinal, and the lab will collect specimen every 6
|| || || || || || || || || || || || ||
hours, for the next 24 hours. - 🔸🔶CORRECT ANSWERS ✔✔Urinate at
|| || || || || || || || || || ||
, specific time, discard the urine, and collect all subsequent urine during the
|| || || || || || || || || || || ||
next 24 hours.
|| || ||
Rationale: Urinate at specific time, discard the urine, and collect all
|| || || || || || || || || ||
subsequent urine during the next 24 hours is the correct procedure for
|| || || || || || || || || || || ||
collecting 24-hour urine specimen. Discarding even one voided specimen
|| || || || || || || || ||
invalidate the test.
|| || ||
The nurse is preparing to administer a histamine 2-receptor antagonist to a
|| || || || || || || || || || ||
client with peptic ulcer disease. What is the primary purpose of this drug
|| || || || || || || || || || || || ||
classification?
||
a. Neutralize hydrochloric (HCI) acid in the stomach
|| || || || || || ||
b. Decreases the amount of HCL secretion by the parietal cells in the stomach
|| || || || || || || || || || || || ||
c. Inhibit action of acetylcholine by blocking parasympathetic nerve endings.
|| || || || || || || || ||
d. Destroys microorganisms causing stomach inflammation. - 🔸🔶CORRECT
|| || || || || || ||
ANSWERS ✔✔Decreases the amount of HCL secretion by the parietal cells in
|| || || || || || || || || || || ||
the stomach
|| ||
Rationale: B correctly describe the action of histamine 2 receptor antagonist
|| || || || || || || || || ||
in helping to prevent peptic ulcer disease.
|| || || || || || ||
The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase
|| || || || || || ||
inhibitor, for a client with Type 2 diabetes mellitus. Which information
|| || || || || || || || || || ||
provides the best indicator of the drug's effectiveness?
|| || || || || || || ||
a. Body max index (BMI) between 20 and 24
|| || || || || || || ||
