HESI RN EXIT Q&A
A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions? ( Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)
1) Stop the infusion 2) Assess vital signs 3) Contact the healthcare provider 4) Document reaction to the drug 5) Initiate an adverse event report.
An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is BEST for administering this prescription?
A) 1000, 1600, 2200, 0400.
The nurse is teaching the parents of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?
A) A diet of healthy fruits, such as bananas and kiwis, are best for the child
An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which actions should the nurse take? select all that apply.
A) Ask if the mother is experiencing any pain with urination. C) Instruct the daughter to check her mother's temperature. E) Determine if the mother has recently experienced a fall.
An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take?
A) Ask the wife to stop and assess the client's swallowing reflex
The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (SATA)
A) Chicken broth B) Apple juice
The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement?
A) Encourage family members to cook meals outdoors and bring the cooked food inside.
A 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?
A) Evaluate the newly hired UAP's level of competency by observing the UAP deliver care
An adult male reports that he recently experience an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolo which maintains his blood pressure at 130/74 mmHg. Which risk factors should the nurse explore further with the client? (SATA)
A) Family health history C) History of hypertension
An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibrillation. Which nursing problems should the nurse include in this client's plan of care? (SATA)
A) Fluid volume excess B) Decreased cardiac output C) Altered peripheral tissue perfusion E) Fatigue
A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?
A) Frequency that the child uses a rescue inhaler during the week
The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication?
A) Hypertension
After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement?
A) Initiate intravenous fluids as prescribed
A female who is undergoing chemotherapy tells the nurse that she plans to volunteer at the elementary school this winter. Which question is best for the nurse to ask this client?
A) Is it possible that you will be in direct contact with the children at the school?
A male client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which interventions should the nurse include in the client's plan of care? (SATA)
A) Monitor cardiac rhythm via telemetry. B) Report changes in pre-existing murmurs. E) Initiate contact transmission precautions.
During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (SATA)
A) Natural whole almonds D) Plain, air-popped popcorn
The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?
A) Ortolani maneuver causing a click at the hip joint
A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. Vital signs are temperature 99.6 F, heart rate 98 beats/minute, respirations 18 breaths/minute, blood pressure 140/82 mmHg and oxygen saturation 88%. Which action should the nurse implement?
A) Prepare for endotracheal intubation
The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child's anxiety, which action is BEST for the nurse to implement?
A) Provide dolls and equipment to re-enact feelings associated with painful procedures
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which interventions should the nurse implement? (SATA)
A) Report serum albumin and globulin levels D) Note signs of swelling and edema E) Monitor abdominal girth
The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?
A) Risk for infection.
A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?
A) Teach technique for scanning the environment
An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. which response is best for the nurse to provide?
A) Tell the client to discuss the medication side effects with the healthcare provider
The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse (SATA)
A) Thirst and frequent requests for bathroom breaks B) Shaking that changes the child's handwriting legibility E) Sunburn with blisters on the face, arms, and hands
The nurse is caring for a client who reports experiencing pain. The client rates the pain as 2 out of 10 on the numeric 1 - 10 pain scale. Which prescription should the nurse administer?
Acetaminophen
A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly?
B) "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away"
A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (SATA)
B) A full pitcher of water is on the bedside table D) The client is lying in a supine position in bed
A client's morning assessment includes bounding peripheral pulses, weight gain of 2 lbs, pitting ankle edema, and moist crackles bilaterally. Which intervention is MOST important for the nurse to include in the client's plan of care?
B) Administer prescribed diuretic.
Which conditions are most likely to respond to treatment with antihistamines? select all that apply.
B) Allergic rhinitis D) Contact dermatitis
When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is BEST for the nurse to implement?
B) Assure the parents that a terminal diagnosis was inevitable.
The nurse is assigning care of a client with prostatitis to a practical nurse (PN). What instruction should the nurse provide the PN regarding care of this client?
B) Avoid urinary catheterization
The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?
B) Brain damage with CP is not progressive but does have a variable course.
A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assess the client's vital signs, pain level, and dressing. Before discharging the client, which intervention should the nurse implement?
B) Check neurovascular status of the distal digits.
A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?
B) Defibrillate with one shock
The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. Which action should the nurse implement?
B) Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.
A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first?
B) Determine type of chemical exposure
The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include?
B) Divide the medication into 2 injections with volumes under 1 mL
The nurse asks the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement?
B) Examine the genitalia as the last part of the total exam
The nurse is assessing a male client with a history of Addison's disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that the he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The healthcare provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed?
B) Hydrocortisone 100 mg IV every 6 hours until systolic BP reaches 110 mmHg
A female client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that "My favorite nurse is on duty now." Which response is BEST for the nurse to provide to this client's dichotomous tendency?
B) I am happy that you are getting better and will be able to go home.
A client in menopause reports being lactose intolerant. She exercises 3 times a week, drinks wine 1 to 3 times a month, and drinks a cup of coffee daily. which instruction should the nurse provide to the client to reduce her risk of developing osteoporosis?
B) Increase calcium intake
A male client with a fracture of the left femur has skeletal traction in place while waiting for surgery. The client is restless and tells the nurse that he needs to urgently urinate. What intervention should the nurse implement?
B) Insert an indwelling urinary catheter
A client with cirrhosis of the liver is having numerous, liquid, incontinent stools, and continues to be confused. In reviewing the client's laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is MOST important for this client to receive?
B) Lactulose
A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury?
B) Limit oral water intake
The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?
B) Names 3 home safety hazards to be resolved immediately.
The nurse is providing teaching to a client who has been recently diagnosed with gestation diabetes mellitus. Which complication poses the GREATEST risk to the fetus is euglycemia is not maintained?
B) Preterm birth
Following morning care, a client with a c-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which interventions should the nurse implement first?
B) Relieve any kinks or obstruction in the client's foley tubing
A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication?
B) Report unusual bruising or bleeding
The nurse notes that an older client has a moist cough that increases in severity during and after meals. Based on this finding, which action should the nurse take?
B) Request a consultant to confirm dysphagia.
A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement?
B) Review the client's current list of medications
The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (SATA)
B) Use a residual limb shrinker C) Wash the stump with soap and water D) Inspect skin for redness
The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?
B) Weight-bearing exercise
During discharge teaching, a male client recently diagnosed with malignant hypertension tells the nurse that he really enjoys downhill skiing and asks if he can continue with this sport. Which is the best response by the nurse?
C) "Cold weather may constrict your blood vessels raising your blood pressure"
What might the nurse suggest to a client with fibrocystic breasts in an attempt to relieve her symptoms
C) "Eliminate caffeine from your diet"
Which class of drugs is the only source of a cure for septic shock?
C) Antiinfectives
At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the PRIORITY nursing problem for this client?
C) Anxiety
A 15-year-old male client was recently diagnosed with the type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement?
C) Assist him in identifying popular fast foods that are within his meal plan for diabetes
A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?
C) Blood transfusions
The mother of a 12-month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experienced a lost of appetite. Which instruction should the nurse provide?
C) CPT should be performed more frequently, but at least an hour before meals
When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? (SATA)
C) Change in the quality of the peripheral pulses D) Loss of sensation to the left lower extremity E) Complaint of increased pain and pressure
A nurse is working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse?
C) Chest discomfort one hour after consuming a large- spicy meal
A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?
C) Current diagnosis of hepatitis B
The nurse should expect a client diagnosed with regional enteritis (Crohn's disease) to exhibit what initial symptoms?
C) Diarrhea, abdominal pain, and weight loss
The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?
C) Dilated pupils, tachycardia, elevated blood pressure, elation
The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobaimain two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. What action should the nurse take?
C) Explain that memory loss and confusion are common with Vitamin B12 deficiency
A client is experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. What is the BEST initial nursing action?
C) Initiate seizure precautions
An older client arrives to the emergency department (ED) with reports of severe nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature 95.4F, heart rate 112 beats/minute, respirations 14 breaths/minute, and blood pressure 74/37 mmHg. Which intervention is most important for the nurse to implement?
C) Keep head of bed raised 45 degrees
A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in this client's plan of care?
C) Monitor the client's cardiac activity via telemetry
Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?
C) Obtain a capillary glucose level
The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every 2 hours. What additional action should the nurse instruct the UAP to take each time the client is turned?
C) Offer the client oral fluids
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 interventions should the nurse take to prepare the body before the family enters the room? (SATA)
C) Place a small pillow under the head. D) Remove resuscitation equipment from the room. E) Gently close the eyes
The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants?
C) Position the infant in a supine position while sleeping
An older client returns to the clinic and receives refills on several medications. The client shares concerns with the nurse about having to take so many medications and asks if one pill could be substituted for many of the others. Which instruction should the nurse implement to address the client's concerns?
C) Use a medication reminder system to prevent forgetting to take the right medications at the right time
The nurse working in the psychiatric clinic has a phone messages from several clients. Which call should the nurse return first?
D) A family member of a client with dementia who has been missing for 5 hours.
What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?
D) Achieve satisfactory pain control
A client is admitted with a severe asthma attack. For the last 3 hours the client has experienced increasing shortness of breath. Arterial blood gas results are: pH 7.22; PaCO2 55 mmHg; HCO3 25 mEq/L (25 mmol/L). Which intervention should the nurse implement?
D) Administer PRN dose of albuterol.
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?
D) An adult who is one day postoperative for a laparoscopic cholecystectomy
After years of struggling with weight management, a middle-age man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care?
D) Apply sequential compression stockings
The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. What is the priority nursing action?
D) Ask the UAP to position the client so the oral medication can be administered.
A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?
D) Assessment of a bruit on the left forearm
The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?
D) Body mass index (BMI) of 17
The nurse is caring for a client is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the input flow. Which actions should the nurse implement first?
D) Continue to monitor intake and output with the next exchange
After initiating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take NEXT?
D) Continue with the blood pressure assessment
The nurse is caring for a client entering the second stage of labor. Which action should the nurse implement first?
D) Convey to the client that birth is imminent
A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?
D) Hemoglobin
The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider IMMEDIATELY?
D) Intensifying headache
When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus, the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?
D) Leave the client's room and return later in the day
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 breath 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 a copy of the client's living will. Which action should the nurse take?
D) Notify the healthcare provider of the client's wishes
A client is admitted with possible urosepsis. Which intervention should the nurse perform as soon as possible?
D) Obtain a urine specimen for a prescribed culture and sensitivity test
Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client?
D) Orthopnea
A client with end-stage renal disease (ESRD) is refusing all treatment and requests that no life-saving measures be implemented. The healthcare provider refuses to write do-not-resuscitate instructions. Which action should the nurse take?
D) Provide the healthcare provider with a copy of the client's bill of rights
A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the IV line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement?
D) Redress the abdominal incision
A male client who was in a motor vehicle collision yesterday is receiving a unit of packed red blood cells. When half of the unit is infused, the client reports lower back pain, and the nurse observes a fine rash over his chest and back. Which intervention should the nurse implement?
D) Replace the transfusion with normal saline
A multiparous client who delivered her infant 3 hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perineal pain after her last delivery. What action should the nurse implement?
D) Review the use of sitz bath equipment with the client.
The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicate to the nurse that the client understands the prescribed diet?
D) Roast turkey, canned vegetables
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?
D) Serum creatinine of 4.5 mg/dL
The wife of a newly-diagnosed client with Parkinson's disease asks the nurse if alternative or complimentary medical therapies might cure the disease. Which response should the nurse provide?
D) Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism.
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?
D) The xenograft is taken from nonhuman sources.
The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal?
D) Vitamin supplements for high-risk pregnant women
