NGN EXIT HESI EXAM QUESTIONS WITH VERIFIED ANSWERS - LATEST UPDATE (GRADED)

The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the admission assessment is relevant to the nurse's plan for taking the blood pressure reading? SATA Blurred Vision Flat Affect frequent syncope 26. After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication? Ask the pt about gastrointestinal pain 27. A pt is receiving enoxaparin 30 mg subcutaneously twice a day. In assessing for adverse effects of the medication, which serum laboratory value most important for the nurse to monitor platelet count 28. A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teach the parents to report which sign of overdose? Bradycardia 29. The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel working on a rehab unit. The UAP asks the nurse how to safely move a physically disabled pt from the... wheelchair to the bed. Which action should the nurse recommend? Place the pt locked wheelchair on the pt strong side next to the bed 4 / 14 30. The nurse has completed the diet teaching of a client who is being discharged following tx of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the pt indicates that the teaching was effective? A tuna fish sandwich with chips and ice cream 31. When conducting diet teaching for a pt who was dx with a myocardial infarction, which snack foods should the nurse encourage the pt to eat? SATA Fresh Turkey slices and berries chick bouillon soup and toast raw unsalted almonds and apples 32. A pt taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first? Observe the appearance of the stool 33. A pt is dx with Meniere's disease. Which problem should the nurse identify as most important in the plan of care? Risk for injury related to vertigo 34. A new nurse preparing to irrigate an IV catheter is attaching a 24 gauge needle. Which action should the charge nurse implement? Suggest the nurse use 20g needle 35. A nurse working on an Endocrine Unit should see which client first? A pt taking corticosteroids who has become disoriented in the last two hours. 36. After an older pt receives tx for drug toxicity the healthcare provider prescribes a 24 hr creatinine clearance, the nurse notes that the pt serum creatinine is 0.3mg. Which action should the nurse implement? Notify the healthcare provider of the results 37. An older adult pt with Systemic inflammatory syndrome (SIRS) has a temp of 101.8, HR of 110, and RR Serum Creatinine of 2mg/dl 5 / 14 of 24 breaths/min. Which additional finding is most important to report to the healthcare provider? 38. A pt in the third trimester of pregnancy reports that she feels some lumpy places in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What actions should the nurse take? Explain that this is normal recreation and can be assessed at the next visit. 39. A pt presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first? begin continuous fetal monitoring 40. The mother of a 2 day old infant girl expresses concern about a flea bite type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer? This is a common newborn rash that will resolve after several days. 41. When assessing a recently delivered mom that her vaginal bleeding is more than expected. Which factor in this history is related to this finding? She is a gravid 6 para 5. 42. The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor? Arterial blood gas 43. A pt who gave birth 48 hours ago has decided to bottle feed teh infant. During the assessment, the nurse observes that both breasts are swollen, warm and tender on palpation. Which instruction should the nurse provide? Apply ice to the breast for comfort. 44. The nurse is providing discharge teaching to the parents of a 13 month old child who underwent repair for an atrial septal defect. The healthcare provider prescribes aspirin and an antibiotic for the first 6 months postoperatively to prevent infective endoBrush the child's teeth everyday and ensure the child receives reg6 / 14 carditis. What information is most important for the nurse discuss with the parents about the child's recovery and prevention of IE. ular dental follow up. 45. A pt who is admitted with complications related to hypopituitarism is diaphoretic and hypotensive. Which assessment finding warrants immediate intervention by the nurse? Lethargy 46. The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs in 24 hours and an elevated central venous pressure for a pt with full thickness burns. Which intervention should the nurse implement? Auscultate for irregular heart rate. 47. A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms require the most immediate intervention by the nurse? Chest discomfort one hour after consuming a large spicy meal. 48. Which self care measure is most important to include in the plan of care of a pt recently diagnosed with type 2 diabetes mellitus? blood glucose monitoring. 49. In assessing a pt with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep. And the pt has become lethargic. Which assessment data should the nurse obtain next? blood glucose 50. An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis? had a cold and ear infection for the past two days. 51. The nurse assesses a pt who had bilateral total knee replacements four hours ago. The nurse notes that the dressing on the right knee is saturated with serosanguineous drainage. What action should the nurse implement? Determine if the wound drainage device is functioning correctly. 7 / 14 52. A pt with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patient? Auscultation of a thrill on the left forearm 53. A client with urge incontinence was treated with onabotulinumtoxinA injections and is now experiencing urinary retention. Which action should the nurse include in the client's plan of care? Remind the pt to practice pelvic floor exercises regularly. 54. A pt is admitted with a dx of urolithiasis. Which finding is most important for the nurse to report to the healthcare provider? Hematuria that is beginning to turn pink 55. The nurse is evaluating the chest drainage system of a patient with a chest tube inserted to treat a left hemothorax. Which finding requires intervention by the nurse? cont. bubbling in the water seal chamber 56. The nurse is caring for a pt who has chronic obstructive pulmonary disease and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a pt with COPD? administering narcotics for pain relief 57. The nurse instructs a pt in use of an incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration?