EXIT HESI PN EXAM WITH VERIFIED
QUESTIONS AND ANSWERS|| GUARANTEED
PASS|| ALREADY GRADED A+|| LATEST
UPDATE
The nurse would be correct in withholding a dose of digoxin in a client with
congestive heart failure without specific instruction from the health care
provider if which finding was documented?
A. Serum digoxin level is 1.5 ng/mL
B. Blood pressure is 104/68 mm Hg
C. Serum potassium level is 2.5 mEq/L
D. Apical pulse is 68/min - ANSWER-C
Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin,
which will increase the chance of dangerous dysrhythmias (normal potassium
level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL
(toxic levels ≥2 ng/mL); (A) is within this range. (B) would not warrant the
nurse withholding the digoxin. The nurse should withhold the digoxin if the
apical pulse is less than 60/min (D).
Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one
UAP. Team 1's assignment includes two clients who are both 1 day
postangioplasty and two clients with unstable angina. Team 2's assignment
includes all stable clients, but two clients are bedridden and incontinent. Which
staffing plan represents the best use of available staff?
A.Team 1: RN team leader, PN; team 2, PN team leader, UAP
,B.Team 1, RN team leader, UAP; team 2, PN team leader, PN
C.Team 1, PN team leader, PN; team 2, RN team leader, UAP
D.Team 1, PN team leader, UAP; team 2, RN team leader, PN - ANSWER-A
Team 1 includes high-risk clients who require a higher level of assessment and
decision making, which should be provided by an RN and PN (A). Team 2 has
stable clients at lower risk than those on team 1. Although two clients on team 2
require frequent care, the care is routine and predictable in nature and can be
managed by the PN and UAP. (B, C, and D) do not use the expertise of the
nursing staff for the high-risk clients.
After administration of an 0730 dose of Humalog 50/50 insulin to a client with
diabetes mellitus, which nursing action has the highest priority?
A.Ensure that the client receives breakfast within 30 minutes.
B.Remind the client to have a midmorning snack at 1000.
C.Discuss the importance of a midafternoon snack with the client.
D.Explain that the client's capillary glucose will be checked at 1130. -
ANSWER-A
Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset
of action is within 30 minutes and the nurse's priority action is to ensure that the
client receives a breakfast tray to avoid a hypoglycemic reaction (A). (B, C, and
D) are also important nursing actions but are of less immediacy than (A).
A 50-year-old man arrives at the clinic with complaints of pain on ejaculation.
Which action should the nurse implement?
A.Teach the client testicular self-examination (TSE).
B.Assess for the presence of blood in the urine.
C.Ask about scrotal pain or blood in the semen.
D.Inquire about a history of kidney stones. - ANSWER-C
,Orchitis is an acute testicular inflammation resulting from recurrent urinary tract
infection, recurrent sexually transmitted disease (STD), or an indwelling
urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the
semen, and penile discharge, so the nurse should determine the presence of
other symptoms (C). Although all men should practice TSE, the client's
symptoms are suggestive of an inflammatory syndrome rather than testicular
cancer (A). Although hematuria (B) is associated with renal disease or calculi
(D), the client's pain is associated with ejaculate, not urine.
Which assessment finding for a client with peritoneal dialysis requires
immediate intervention by the nurse?
A.The color of the dialysate outflow is opaque yellow.
B.The dialysate outflow is greater than the inflow.
C.The inflow dialysate feels warm to the touch.
D.The inflow dialysate contains potassium chloride. - ANSWER-A
Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse
should obtain a specimen for culture, assess the client, and notify the health care
provider (A). (B and C) are desired. (D) is commonly done to prevent
hypokalemia.
The nurse is teaching a client newly diagnosed with diabetes mellitus about the
subcutaneous administration of Regular and NPH insulin. Which statement
indicates that the client needs further instruction?
A."I should balance my daily exercise with my dietary intake and insulin
dosages."
B."When I give myself an injection, I should aspirate to make sure that I am not
in a blood vessel."
C."I should inject my insulin into a different site to reduce the development of
scar tissue."
D."I should remove the dose of clear insulin first and then the dose of cloudy
insulin from the vials." - ANSWER-B
, Aspiration (B) is not necessary when giving insulin because it could increase
tissue trauma and affect the absorption rate. (C) helps minimize tissue atrophy,
which can affect the absorption of the insulin. (A and D) are correct procedures.
The client should balance an active physical lifestyle with diet, insulin, and
blood glucose monitoring to ensure good serum glucose control. When mixing
insulins in the same syringe, the clear (Regular) insulin is withdrawn first to
avoid contamination of the clear vial with cloudy NPH insulin, which will alter
the absorption rate of the remaining Regular insulin.
The nurse formulates a nursing diagnosis of pain related to muscle spasms for a
client with extreme lower back pain associated with acute lumbosacral strain.
Which is the best intervention for the nurse to implement?
A.Perform range-of-motion exercises on the lower extremities every 4 hours.
B.Place a small firm pillow under the upper back to flex the lumbar spine
gently.
C.Rest in bed with the head of the bed elevated 20 degrees and flex the knees.
D.Position in reverse Trendelenburg with the feet firmly against the foot of the
bed. - ANSWER-C
Resting in bed with the head of the bed elevated 20 degrees and flexing the
knees reduces stress on the lower back muscles (C). Range-of-motion exercises
can result in paravertebral muscle spasms and increased pain (A). Bending the
knees, rather than (B), reduces stress on the lower back. (D) places stress on the
lower back and increases the client's pain.
The nurse plans to evaluate the effectiveness of a bronchodilator. Which
assessment datum indicates that the desired effect of a bronchodilator has been
achieved?
A.Increased oxygen saturation
B.Increased urinary output
C.Decreased apical pulse rate
QUESTIONS AND ANSWERS|| GUARANTEED
PASS|| ALREADY GRADED A+|| LATEST
UPDATE
The nurse would be correct in withholding a dose of digoxin in a client with
congestive heart failure without specific instruction from the health care
provider if which finding was documented?
A. Serum digoxin level is 1.5 ng/mL
B. Blood pressure is 104/68 mm Hg
C. Serum potassium level is 2.5 mEq/L
D. Apical pulse is 68/min - ANSWER-C
Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin,
which will increase the chance of dangerous dysrhythmias (normal potassium
level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL
(toxic levels ≥2 ng/mL); (A) is within this range. (B) would not warrant the
nurse withholding the digoxin. The nurse should withhold the digoxin if the
apical pulse is less than 60/min (D).
Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one
UAP. Team 1's assignment includes two clients who are both 1 day
postangioplasty and two clients with unstable angina. Team 2's assignment
includes all stable clients, but two clients are bedridden and incontinent. Which
staffing plan represents the best use of available staff?
A.Team 1: RN team leader, PN; team 2, PN team leader, UAP
,B.Team 1, RN team leader, UAP; team 2, PN team leader, PN
C.Team 1, PN team leader, PN; team 2, RN team leader, UAP
D.Team 1, PN team leader, UAP; team 2, RN team leader, PN - ANSWER-A
Team 1 includes high-risk clients who require a higher level of assessment and
decision making, which should be provided by an RN and PN (A). Team 2 has
stable clients at lower risk than those on team 1. Although two clients on team 2
require frequent care, the care is routine and predictable in nature and can be
managed by the PN and UAP. (B, C, and D) do not use the expertise of the
nursing staff for the high-risk clients.
After administration of an 0730 dose of Humalog 50/50 insulin to a client with
diabetes mellitus, which nursing action has the highest priority?
A.Ensure that the client receives breakfast within 30 minutes.
B.Remind the client to have a midmorning snack at 1000.
C.Discuss the importance of a midafternoon snack with the client.
D.Explain that the client's capillary glucose will be checked at 1130. -
ANSWER-A
Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset
of action is within 30 minutes and the nurse's priority action is to ensure that the
client receives a breakfast tray to avoid a hypoglycemic reaction (A). (B, C, and
D) are also important nursing actions but are of less immediacy than (A).
A 50-year-old man arrives at the clinic with complaints of pain on ejaculation.
Which action should the nurse implement?
A.Teach the client testicular self-examination (TSE).
B.Assess for the presence of blood in the urine.
C.Ask about scrotal pain or blood in the semen.
D.Inquire about a history of kidney stones. - ANSWER-C
,Orchitis is an acute testicular inflammation resulting from recurrent urinary tract
infection, recurrent sexually transmitted disease (STD), or an indwelling
urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the
semen, and penile discharge, so the nurse should determine the presence of
other symptoms (C). Although all men should practice TSE, the client's
symptoms are suggestive of an inflammatory syndrome rather than testicular
cancer (A). Although hematuria (B) is associated with renal disease or calculi
(D), the client's pain is associated with ejaculate, not urine.
Which assessment finding for a client with peritoneal dialysis requires
immediate intervention by the nurse?
A.The color of the dialysate outflow is opaque yellow.
B.The dialysate outflow is greater than the inflow.
C.The inflow dialysate feels warm to the touch.
D.The inflow dialysate contains potassium chloride. - ANSWER-A
Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse
should obtain a specimen for culture, assess the client, and notify the health care
provider (A). (B and C) are desired. (D) is commonly done to prevent
hypokalemia.
The nurse is teaching a client newly diagnosed with diabetes mellitus about the
subcutaneous administration of Regular and NPH insulin. Which statement
indicates that the client needs further instruction?
A."I should balance my daily exercise with my dietary intake and insulin
dosages."
B."When I give myself an injection, I should aspirate to make sure that I am not
in a blood vessel."
C."I should inject my insulin into a different site to reduce the development of
scar tissue."
D."I should remove the dose of clear insulin first and then the dose of cloudy
insulin from the vials." - ANSWER-B
, Aspiration (B) is not necessary when giving insulin because it could increase
tissue trauma and affect the absorption rate. (C) helps minimize tissue atrophy,
which can affect the absorption of the insulin. (A and D) are correct procedures.
The client should balance an active physical lifestyle with diet, insulin, and
blood glucose monitoring to ensure good serum glucose control. When mixing
insulins in the same syringe, the clear (Regular) insulin is withdrawn first to
avoid contamination of the clear vial with cloudy NPH insulin, which will alter
the absorption rate of the remaining Regular insulin.
The nurse formulates a nursing diagnosis of pain related to muscle spasms for a
client with extreme lower back pain associated with acute lumbosacral strain.
Which is the best intervention for the nurse to implement?
A.Perform range-of-motion exercises on the lower extremities every 4 hours.
B.Place a small firm pillow under the upper back to flex the lumbar spine
gently.
C.Rest in bed with the head of the bed elevated 20 degrees and flex the knees.
D.Position in reverse Trendelenburg with the feet firmly against the foot of the
bed. - ANSWER-C
Resting in bed with the head of the bed elevated 20 degrees and flexing the
knees reduces stress on the lower back muscles (C). Range-of-motion exercises
can result in paravertebral muscle spasms and increased pain (A). Bending the
knees, rather than (B), reduces stress on the lower back. (D) places stress on the
lower back and increases the client's pain.
The nurse plans to evaluate the effectiveness of a bronchodilator. Which
assessment datum indicates that the desired effect of a bronchodilator has been
achieved?
A.Increased oxygen saturation
B.Increased urinary output
C.Decreased apical pulse rate
