HESI EXIT V4 2022

An older adult male reporting abdominal pain is admitted to the hospital from a long -term care facility . It has been 7 days since his last bowel movement , his abdomen is distended , and he just vomited 150 of dark brown emesis . In what order should the nurse implement these interventions ? ( Arrange with the highest priority intervention on top , and lowest priority intervention on bottom )

1. Elevate the head of the bed. 2. Offer PRN pain medication. 3. Complete focused assessment. 4. Send emesis sample to the lab.

Heparin 0.4 units/kg/minute IV is prescribed for a client who weighs 110 pounds The available solution is labeled Heparin Sodium 25,000 5% Dextrose Injection 250 mL The nurse should program the infusion pump to deliver how many ? (Enter numeric

12

What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

Achieve satisfactory pain control.

Four hours after the administers Interferon subcutaneously to a client, the client develops a headache, muscle aches and a fever of 101.8° F (38.8°C). What action should the nurse implement?

Administer a prescribed PRN dose of acetaminophen for these side effects.

A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures . The nurse notes that the client's admission prescriptions include radiation therapy . What action should the nurse implement ?

Ask the client about his expected goals for this hospitalization

For the second time in four months , an overweight client is seen in the clinic because of vulvovaginitis resulting from a Candida infection. Which Intervention should the nurse implement first ?

Ask the client about recent sexual activity.

An adult client is admitted to the psychiatric unit with a diagnosis of major depression After two weeks of antidepressant medication therapy the notices the client has more energygiving personnal belongings away to visitorsand is in a better mood Which intervention is best for the to implement ?

Ask the client if there are any recent thoughts of harming self.

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incidentWhile providing care to chlid, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take?

Ask the older brother how he felt during the incident.

The nurse observes an unlicensed assistive personnel (UAP ) who is preparing to provide personal care for a client who requires contact precautions The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves . What action should the nurse take ?

Assist the UAP with application of a face mask or face shield.

The nurse identifies an electrolyte imbalance , an elevated pulse rate, and an elevated blood pressure for a client with chronic kidney disease Which is the most important action for the nurse to take?

Auscultate for irregular heart rate.

A client with chronic kidney disease (CKD ) is admitted in heart failure (HF) and is complaining of shortness of breath and a headache Assessment findings include: BP 180/90 mm Hgheart rate 130 beats/minute, oxygen saturation 89%, and temperature 100F (37.8C)A temporary catheter is inserted for immediate hemodialysis and the client is scheduled for placement of an arteriovenous (AV) fistula in the left arm. Which act should the nurse implement ?

Avoid using the left arm for IV access.

A client has received a prescription for orlistat for weight and nutrition management . In addition to the medication , the client plans to take a multivitamin. What teaching should the nurse provide ?

Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness.

When the nurse enters the room of a male client who was admitted for a fractured femur , his cardiac displays a normal sinus rhythm (NSR) but he has no spontaneous respirations and his carotid pulse is not palpable . Which intervention should the nurse implement ? S

Begin chest compressions at 100/minute

A child is diagnosed with acquired aplastic anemia . The nurse knows that this child has the best prognosis with which treatment regimen ?

Blood transfusions.

A male client who is experiencing musculoskeletal pain is discharged with instructions to take Ibuprofena nonsteroidal antidrug mouth BID. After receiving discharge teaching, the client states he plans to take the medication twice daily with breakfast and dinner How respond ?

Confirm that the client has an effective plan for when to take the medication

A client at 28- weeks gestation is admitted to the obstetrical unit following her involvement in a motor vehicle collision. After stabilizing the nurse a fetal monitor reading What action should the nurse take if fetal tachycardia is assessed on the monitor?

Contact the healthcare provider after initiating oxygen per face mask.

The nurse knows that several complications can occur with the administration of blood Which finding is an indication of an air

Difficult breathing.

While a child is hospitalized with acute glomerulonephritis , the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate ?

Elevated blood pressure must be anticipated and identified quickly.

The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Engage the client in non-threatening conversations.

An adult woman who has a history of inferior myocardial infection, esophageal reflex, and type 1 diabetes mellitus (OM) is admitted to the telemetr unit for sudden onset of dizzines with palpitations and a burning sensation in her chest. Which intervention should the nurse implement first?

Evaluate telemetry cardiac rhythm

The nurse is preparing an adult with Addison's disease for self - management. Which information should the nurse include in

Events requiring steroid dose adjustments.

An older adult female asks the clinic nurse about getting a Herpes vaccination because she gets cold sores on her mouth when she is sick or stressed How should the nurse respond ?

Explain the user of vaccination to reduce risk for Herpes zoster.

The nurse is taking the blood pressure measurement of a client with Parkinson's diseaseWhich information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? (Select all that apply .)

Frequent syncope. Blurred vision.

When conducting diet teaching for a client who was diagnosed with a myocardial Infarction, which snack foods should the nurse encourage the to eat? ( Select all that apply .)

Fresh turkey slices and berries. Raw unsalted almonds and apples.

What is the primary purpose for initiating nursing interventions that promote good nutrition, rest and exercise, and stress reduction for clients diagnosed with an HIV infection ?

Improve function of the immune system.

A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics Which intervention should the nurse implement first ? Please scroll and view each tab's information in the client's medical record before the answer

Infuse 0.9% sodium chloride 500 mL bolus

The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI ) Which client complaint is -threatening and should be reported to the healthcare provider immediately ?

Intensifying headache

A client with chronic kidney disease (CKD ) is discharged with a prescription for epoetin alfa subcutaneously In teaching the client about the medication , the nurse should emphasize the benefit of Increasing which food product in the diet ?

Iron-rich foods.

The nurse inserts an indwelling urinary catheter as seen in the video What action should the nurse take next ? (Please view the video before selecting the option that applies To repeat the video , click the play button again )

Leave the catheter in place and obtain a sterile catheter.

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?

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

A client is receiving a hypotonic solution for bladder imigation and is at risk for hyponatremia The nurse should sign of hyponatremia ?

Mental status changes.

While changing a client's postoperative dressing , the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor Before reporting this finding to the healthcare provider , the nurse should evaluate which of the client's laboratory values?

Neutrophil count.

A client with leukemia undergoes a bone marrow biopsy The client's laboratory values indicate the client has thrombocytopenia Based on the which nursing assessment is most important following the procedure ?

Observe aspiration site.

A client with a history of upper respiratory symptoms is admitted with chest tightness , a productive cough and breathing The blood (ABGs ) indicate respiratory An increase in which laboratory test result supports this ?

PaCO2

The nurse caring for a group of clients with the help of a practical nurse (PN ). Which nursing actions should the nurse assign to the Select that apply )

Perform daily surgical dressing change for a client who had abdominal hysterectomy. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM) Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty

A nurse who works in the nursery is attending the vaginal delivery of a term infant What action should the nurse complete leaving the deliver room?

Place the ID bands on the infant and mother.

The nurse is caring for a client with a suspected diagnosis of osteomyelitis . Which diagnostic test should the nurse prepare the client to expect the healthcare provider to prescribe?

Radionuclide bone scan.

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?

Related personal values.

The nurse on a pediatric unit of a healthcare facility observes a colleague leaving an open client electronic health record (EHR ) taking a lunch break Which action should the nurse take ?

Remind the colleague of information security principles.

The nurse provides teaching about a scheduled procedure to a male client who was admitted for diagnostic testing to determine the extent of metastasis of his cancer. An hour later the client asks the nurse for information about the scheduled procedure What action should the nurse Implement ?

Repeat the client teaching and leave written instructions for the client.

While the nurse is conducting an admission assessment of a female client with bipolar disorder , the client suddenly begins to take off her clothes and throw them about the room . Which action should the nurse take first ?

State it is unacceptable to undress during the interview.

A male client with hypertension , who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate blood pressure (BP ) BP 158/105 mmHg and he admits that he has not been taking the prescribed medication because the drugs make Teel bad In explaining the need for hypertension control , the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition ?

Stroke secondary to hemorrhage.

A group of nurses implement a pilot study to evaluate a proposed evidence - based change to providing client care Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility Which actions should be taken ? (Select all that apply

Submit a Sentinel event report to the research committee. Invite data review by the quality improvement department. Propose clinical practice guidelines to nursing committee.

A middle-aged male client at the outpatient clinic receives a prescription for tetracycline due to folliculitis of the scalp. Which instruction should the clinic nurse provide?

Take the medication with a glass of water two hours after meals.

Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time?

The antifungal nystatin suspension , for a client who has just brushed his teeth .

When teaching a group of school-aged children how to reduce the risk for Lyme disease , which instruction should the camp nurse include

Wear long sleeves and pants.

A preschool -aged child who is being treated for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever Which assessment provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria? ​

White coating on tongue.

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infectionWhich food the nurse encourage this client to eat?

Yogurt of buttermilk.

A client becomes increasingly lethargic and has a respiratory rate of 8 breaths per minute with 30-second periods of apnea. The healthcare provide and STAT arterial blood gases (ABG) are drawn. What ABG results should the nurse anticipate?

Uncompensated

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which should the in the discharge teaching plan? (Select that apply)

Use recliner for long periods of time Continue wearing compression stockings. Avoid prolonged standing or sitting.