HESI RN EXIT EXAM V1 Rated A+

1 the nurse is caring for a group of clients with the help of a practical nurse. Which nursing actions should the nurse assigned to the PN? – 1 perform daily surgical dressing change for a client who had an abdominal hysterectomy 2 obtain post-operative vital signs for a client one day following unilateral knee arthroplasty 3 administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus 2 A lethargic one hour old infant is brought to the nursery for further assessment. In what order should the nurse assess this infant? – 1 Heart rate 2 respirations 3 temperature 4 heel stick 3 following a gunshot wound, an adult client has a hemoglobin level of 4. The nurse prepares to administer a unit of blood for an emergency transfusion. The client has ab negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is no type Ab negative blood currently available. Which intervention should the nurse implement? - administering normal saline solution until type Ab negative is available 4 a female client receives a prescription for alendronate sodium (Fusamax) to treat her newly diagnosed osteoporosis. What instructions should the nurse include in the client teaching plan? - take on an empty stomach with a full glass of water 5 a male client with cirrhosis has jaundice and Puritas. He tells the nurse that he has been soaking in hot bath at night with no relief of his discomfort. What action should the nurse take? - encourage the client to use cooler water and apply calamine lotion after soaking 6 an adult female tells the nurse that her grandmother was diagnosed with colorectal cancer at age 75. The client is implementing measures to reduce her own risk. Which of the clients plans indicates the need for additional information? - annual sigmoidoscopy screening 7 a mother runs into the emergency department with a toddler in her arms and tell the nurse that her child got into some cleaning products. The child smells of chemicals on the hands face and the front of the child's clothing. After ensuring an patent Airway, what action should the nurse Implement first? - determine type of chemical exposure 8 the nurse enters the room of a client with Parkinson's disease who is taking levodopa. The client is a rising slowly from the chair while the UAP stands next to the chair. What action should the nurse take? - a firm that the client should arrive slowly from the chair 9 a middle-aged female client tells the clinic nurse that she has lost an inch of height in the last year. What is the priority nursing intervention? - assist the client to schedule a bone density exam 10 an atypical antipsychotic, ziprasidone, is prescribed for a client with a diagnosis of schizophrenia. After the client has been taking the medication for two weeks, the nurse assesses the Drug's effectiveness. which client reports suggest that the medication is helpful? - hears voices less often 11 prior to obtaining a trapeze bar for a client with limited Mobility, which client assessment is most important for the nurse to obtain? - upper body muscle strength 12 a male client with heart failure reports heart palpitations and difficulty breathing when lying flat. When he requests additional pillows, the nurse determines that his heart rate is 125 beats per minute and respiratory rate is 22 breaths per minute. Which intervention is most important for the nurse to implement? - obtain manual blood pressure 13 a family member reports that the client who is bedridden has not been turned or repositioned all night and is sleeping on a special air mattress with no sheets. What information should the nurse provide to the family member? - clarify that an aerated support surface does not use sheets that often cause skin breakdown 14 an S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? - document in the client's record 15 the nurse is evaluating the diet teaching of a client with hypertension. What dinners selection indicates that the client understands the dietary recommendations for hypertension? - baked pork chop, apple sauce, corn on the cob, 1% milk, and key lime pie 16 a client who had a percutaneous coronary intervention two weeks ago returns to the clinic for a follow-up visit. The client had a post-operative ejection fraction of 30%. Today the client has lungs which are clear, slight pedal edema, and a 5 pound weight gain. Which interventions should the nurse implement? - assess compliance with routine prescriptions 17 the nurse is completing an admission assessment for a male client with paranoid schizophrenia. The client tells the nurse that the staff dislikes him. What action should the nurse take? - determine if the client has formulated any plans regarding the staff 18 an adult male was diagnosed with stage 4 lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse? - explain that the client will start to lose consciousness and his body systems will slow down 19 a client with a history of adrenal insufficiency is admitted to the ICU with an acute adrenal crisis. the client is complaining of nausea and joint pain. Vital signs are temperature 102, heart rate 138, BP 80 / 60. which intervention should the nurse Implement first? - Infuse an intravenous fluid bolus 20 following morning care, a client with a C5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse Implement first? - relieve any kinks or obstruction in the clients Foley tubing 21 when caring for a client with a traumatic brain injury who had a craniotomy for increased intracranial pressure, the nurse assesses the client using the Glasgow Coma Scale every 2 hours. For the past 8 hours the clients g c s score has been 14. What does this finding indicate about this client? - neurologically stable without indications of an increased ICP 22 the nurse is planning care for a young adult client with acromegaly. It is most important for the nurse to monitor which of the following clients serum lab test results? - glucose 23 a child newly diagnosed with sickle cell anemia is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? - instructions about how much fluid the child should drink daily 24 a young adult female present at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? - last menstrual period Was 7 weeks ago 25 while caring for a client post-operative dressing, the nurse observes purulent wound drainage. previously the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take? - request a culture and sensitivity of the wound 26 when administering Ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse? - Stridor 27 the nurse completed a dressing change for a client with partial thickness Burns to both lower legs. After completing the dressing change, what intervention should the nurse implement? - perform passive range of motion 28 the nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using a Medela Haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipples elongated tip in the back of the oral cavity. What instructions should the nurse provide to the mother about feedings? - hold a newborn in an upright position 29 the nurse is supervising a UAP who will be providing personal care for a client with watery diarrhea caused by clostridium difficile. which action by the nurse takes priority? - review use of personal protective equipment with the UAP 30 a client is admitted to the ICU with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? - hypokalemia 31 a 17 year old adolescent is brought to the emergency department by both parents because they have been coughing and running a fever with flu like symptoms for the past twenty-four hours. Which intervention should the nurse Implement first? - place a mask on the client's face 32 a client is admitted to a medical unit with a diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke syndrome? - thiamine 33 the nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease. Which assessment findings should the nurse report to the healthcare provider? - the appearance of the returning dialysate fluid is cloudy 34 the nurse is preparing to administer an IV dose of Ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse? - serum creatinine of 4.5 35 the nurse enters the room of a client who is awaiting surgery for appendicitis. The UAP has helped the client to a position of comfort with the right leg flexed and has applied a heating pad to the client abdomen to relieve the pain. Which action should the nurse Implement first? - remove the heating pad from the clients abdomen 36 following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. What action should the nurse take? - apply bilateral eye Shields to reduce photosensitivity 37 the healthcare provider prescribed Furosemide for a four-year-old child who has a ventricular septal defect. Which outcome indicates to the nurse that the pharmacological intervention was effective? - daily weight decrease of 2 lb