HESI EXIT

A client with chronic obstructive pulmonary disease (COPD) smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. The client reports difficulty controlling respiratory distress at home when using the rescue inhaler. Which comment from the client indicates to the nurse that the client is not using the inhaler properly?

- "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away."

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

- An adult who is one day postoperative for a laparoscopic cholecystectomy.

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states, "It still takes at least two hours to fall asleep at night." Which action should the nurse implement?

- Ask the client for a description of the exercise schedule that is being followed.

A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?

- Assessment of a bruit on the left forearm.

The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first?

- Cefazolin 1 gram intravenously every 6 hours.

While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin-resistant Staphylococcus aureus (MRSA). To reduce the risk of recurrence of the MRSA in the postoperative wound, which intervention is most important for the nurse to implement?

- Change the surgical dressing readily when soiled.

While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

- Discontinue the IV site after inserting a new access

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 Ibs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

- Ensure client takes a diuretic every morning.

A client who was rescued from a house fire is admitted to the burn unit with deep dermal, partial thickness (second degree) burns over approximately one-third of the back and upper thighs. The nurse begins administration of prescribed crystalloid fluids for the first 24-hours following the burn incident. Which physiological response is promoted by the administration of the fluids?

- Fluid resuscitation due to capillary leaking.

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

- Give a dose of regular insulin as prescribed.

A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

- Increasing confusion of the client

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

- Instruct the client that it is important to reduce the dose of the medication gradually

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

- Instruct the parent to change the child's diaper more often

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

- Notify information services department of the situation.

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

- Notify the healthcare provider if the client reports any allergies to iodine or shellfish

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

- Notify your healthcare provider if you start having abdominal pain

The nurse is performing a functional assessment on an older client who lost five pounds (2.27 Kg) of weight since the last visit 12 weeks ago, and who reports a decrease in energy and appetite. Which action should the nurse include during the assessment?

- Question the client about the frequency of falls in recent months.

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

- Report the complaint of eye pain to the surgeon.

An older client's spouse reports to the nurse that there has been a behavior change in the client for the past several days. The client was recently seen by the healthcare provider at the clinic and was treated for seasonal allergies and insomnia. Which action is most important for the nurse to implement?

- Review medications for drug and food interactions.

A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

- Rhythm of apical pulse.

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

-A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB).

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry. The client's blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

-Abnormal level of consciousness..

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

-Apply a cool pack to the injection site to reduce discomfort.

A client with coronary artery disease (CAD) is admitted to the medical unit for testing. The client describes having had frequent episodes of angina over the last few days prior to admission. The client is now experiencing shortness of breath, nausea, and chest pressure. After obtaining the client's vital signs, which action should the nurse take next?

-Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%.

After years of struggling with weight management, a middle-aged adult client is evaluated for gastroplasty. The client has experienced difficulty with managing diabetes mellitus and hypertension, but is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care?

-Apply sequential compressign stockings.

An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?

-Ask the spouse to stop and assess the client's swallowing reflex.

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

-Assess for symmetrical chest movement. -Auscultate for presence of bilateral breath sounds. -Obtain a portable chest x-ray to verify ETT location.

The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?

-Assist to a high Fowler's position.

A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history includes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?

-Avoid the consumption of wine, beer, and coffee.

CORRECT ORDER:

-BREATHING PATTERN -BP -TEMP -EDEMA

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

-Carry on with surgical preparation of the client without a signed informed consent..

A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client reports pain at the right groin insertion site. Which action should the nurse implement?

-Check femoral site for hematoma formation.

A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take? Reference Range: High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]

-Confirm that this value is helpful in reducing cardiac risk.

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

-Continue with the blood pressure assessment.

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

-Defined area of persistent redness over bone.

A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

-Depletion of clotting factors.

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

-Destruction of joint cartilage

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse brought a luer-lock tipped syringe. Which action should the charge nurse take?

-Direct the nurse to attach the luer-lock tip to the irrigation port.

SOMETHING ABOUT A HURRICANE

-Drinking water contaminated by sewage.

newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

-Evaluate the newly hired UAP's level of competency by observing the UAP deliver care.

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

-Expect a persistent cough after the procedure.

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

-Explain that reinfections occur from sex with untreated partners.

An adult client was diagnosed with stage IV lung cancer three weeks ago. The client's spouse approaches the nurse and asks how to know that the spouse's death is imminent because their two adult children want to be there when the client dies. Which is the best response by the nurse?

-Explain that the client will start to lose consciousness and the body systems will slow down.

After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient. During a follow-up visit at the community clinic, the nurse observes that the client has developed jaundice. Which action should the nurse take?

-Explain the need to evaluate liver function.

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

-Finish the procedure..

A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever and cough for the last two days. Which finding should alert the nurse that the child is in acute respiratory distress?

-Flaring of the nares.

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? Select all that apply.

-Gently close the eyes. -Remove resuscitation equipment from the room. -Place a small pillow under the head.

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

-Immunizations that are available.

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

-Include no more than 1-2 alcoholic beverages in diet per day.

A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a Pa02 of 92 mm Hg. Which intervention should the nurse implement?

-Increase rate of ventilation.

A client presents to the emergency department with nausea, vomiting, and diarrhea. While obtaining the history and physical assessment, the nurse discovers that the client's significant other is recovering from COVID 19. After obtaining a nasal swab to test the client for COVID 19, which action is most important for the nurse to take?

-Institute droplet precautions, place client in a private room, and keep the door closed.

The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

-Keep the nails trimmed short.

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

-LOW FAT DAIRY

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

-Leave the client's room and return later in the day.

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

-Maintain strict intake and output..

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

-Monitor the client's white blood cell count. -Send wound drainage for culture and sensitivity. -Institute contact precautions for staff and visitors.

25) Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

-Muscle pain

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

-Names 3 home safety hazards to be resolved immediately.

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

-Neutrophil count.

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

-Neutrophil count.

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

-Nitroglycerin.

An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the client's living will. Which action should the nurse take?

-Notify the healthgare provider of the client's wishes.

A client admitted to the ICU with a spinal cord injury following a MVC. Which nurse should be contacted to coordinate the progression of the clients care?

-Nurse case manager

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)

-ON THE NOSE

The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. Which intervention should the nurse should perform in the immediate management of the client?

-Obtain a focused history to determine recent bleeding and use of anticoagulants.

A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

-PAIN SCALE

A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis. The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements. Which factor is the most likely cause for this problem?

-Pain when eating.

nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

-Plain baked sweet potato..

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

-Positive Epstein-Barr, and malaise.

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

-Procure platelet products from the blood bank

A client is admitted with bipolar disorder, manic psychosis. The client is placed in seclusion after unsuccessful attempts by staff at deescalating the client during a sudden mood swing from laughter to jumping and screaming threats while waving a plastic dinner knife. The client is given haloperidol 5 mg IM STAT prior to seclusion. Which intervention is most important for the nurse to implement immediately after seclusion?

-Provide one-on-one observation at all times..

While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

-Pull up a chair and sit beside the client's bed.

1) A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

-Remove soft drink cans from the nurse's desk and patient lounge.

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

-Replace fluids IV based on intake and output.

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

-Report any painful urination, blood in urine, or fever.

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

-Right foot is cool to the touch and appears pale and blanched.

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet?

-Roasted turkey, canned vegetables.

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity. Which test should the nurse schedule the client for evaluation of the symptoms? .

-Spirometry

The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

-Take prescribed cortisone accurately.

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.

-The client is lying in a supine position in bed. -A full pitcher of water is on the bedside table.

A client who is admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor. Which assessment finding places the client at greatest risk?

-Unresponsive to gaginful stimuli.

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

-Use distraction and therapeutic communication skills.

The nurse is developing an educational program for older adult clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristic(s)? Select all that apply.

-Uses pictures to help illustrate complex ideas. _Contains a list with definitions of unfamiliar terms. -Uses common words with few syllables.

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

-Watery diarrhea.

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

-Yogurt or buttermilk

An older adult client who fell at the store is admitted with a possible fracture of the right hip. Which assessment finding should the nurse report to the healthcare provider?

-right leg externally rotated and shorter than left

A cient who weighs 132 lb receives a prescription for lorazepam 44 mcg/kg IV to be administer 20 minutes before a scheduled procedure. The medication is available in 2 mg/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

1.3

The healthcare provider prescribes amoxicillin 1.5 grams PO daily, in equally divided doses to be administered every 8 hours. The medication is available in a bottle labeled, Amoxicillin suspension 200 mg/5 mL." How many mL should the nurse administer every 8 hours? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

12.5

A client receives a prescription for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline. How many ml/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

18

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

21

A child who weighs 55 lb receives a prescription for cefotaxime 150 mg/kg/day IV in divided doses every 6 hours. How many mg should the nurse administer each day?

3750

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

Fruits without sauce. Fresh or frozen vegetables without sauce.

Rationale

Furosemide is used in clients with heart failure to relieve pulmonary congestion. Therapeutic results would include increased urine output, decreased blood pressure if the client is hypertensive, and decreased adventitious sounds in the lungs. A non-therapeutic side effect of furosemide is hypokalemia.

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

Oatmeal, banana, and herbal tea.

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Palpate the area above the pubic symphysis.

When providing client care, the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important?

Relevance to the situation

The nurse on the medical-surgical unit is receiving a transfer report from the postanesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy. The PACU nurse provides the following information: "1,000 mL 0.9% sodium chloride is infusing at 125 mL/hr into the left wrist with 600 mL remaining. Ondansetron 4 mg IV every 8 hours is prescribed for nausea. The last dose was administered at 0700. The client is currently describing pain at a level 2 on a 0 to 10 pain scale.

Soft abdomen, absent bowel sounds, no bleeding on dressing.

The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94% on room air; Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L); Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L); and Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm° (14 x 109/). Which intervention should the nurse implement?

Verify that Client B has two units of packed cells available.

The nurse is assessing a 3month -old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which s/s

restlessness clenched fists increased respiratory increased pulse