HESI Review EXIT EXAM 2020

•             Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?

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•             A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel 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?

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•             The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?

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•             An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?

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•             A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client’s teaching plan?

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•             A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?

•             In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement?

•             Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratory rate is within normal limits.

•             During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs?

•             During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first?

•             At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

•             After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?

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•             A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?

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•             A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?

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•             Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication?

•             “I have a headache that gets worse when I sit up”

•             “I am having pain in my lower back when I move my legs”

•             “My throat hurts when I swallow”

•             “I feel sick to my stomach and am going to throw up”

•             An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

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•             The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child’s dietary restrictions. Which foods are contraindicated for this child?

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•             Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?

•             Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis?

•             The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)?

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•             A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first?

•             Cleanse the foot with soap and water and apply an antibiotic ointment

•             Provide teaching about the need for a tetanus booster within the next 72 hours.

•             have the mother check the child’s temperature q4h for the next 24 hours

•             transfer the child to the emergency department to receive a gamma globulin injection

•             The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement.” What instruction should the nurse provide?

•             A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences

•             Bradycardia and constipation

•             Lethargy and lack of appetite

•             Muscle cramping and dry, flushed skin

•             Palpitations and shortness of breath

•             A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?

•             The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.)

•             Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour

•             The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply)

•             The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies)

•             Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence created by the heart or valvular defect.

•             The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth)

•             rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml

•             The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?

•             Auscultate the client’s bowel sounds

•             Observe for edema around the ankles

•             Measure the client’s capillary glucose level

•             Count the apical and radial pulses simultaneously

•             Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client’s bowel sounds

•             A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?

•             A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?

•             A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask?

•             Rationale: The pattern of reported manifestations is suggestive of hypothyroidism

•             After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? 

•             Capillary refill of 8 seconds

•             bruises on arms and legs

•             round and tight abdomen

•             pitting edema in lower legs

•             After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse’s signature on the client’s surgical consent form? (Select all that apply)

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•             Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement?

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•             A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

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•             The client with which type of wound is most likely to need immediate intervention by the nurse?

•             Laceration

•             Abrasion

•             Contusion

•             Ulceration

•             Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut.

•             The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care?

•             Rationale:A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Although pheochromocytoma has classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified as sites of mutations leading to pheochromocytoma.

•             When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention?

•             To reduce abdominal pressure on the diaphragm

•             to promote retraction of the intercostal accessory muscle of respiration

•             to promote bronchodilation and effective airway clearance

•             to decrease pressure on the medullary center which stimulates breathing

•             Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing.

•             When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation?

•             The client is too obese

•             Palpating in the wrong abdominal quadrant

•             Deeper palpation technique is needed

•             The gallbladder is normal

•             Rationale: a normal healthy gallbladder is not palpable

•             A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

•             describe the transmission of drugs to the infant through breast milk

•             encourage her to use stress relieving alternatives, such as deep breathing exercises

•             Inform her that some antianxiety medications are safe to take while breastfeeding

•             Explain that anxiety is a normal response for the mother of a 3-week-old.

•             Rationale: there are several antianxiety medications that are not contraindicated for breastfeeding mothers.

•             An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?

•             Start an intravenous (IV) infusion of normal saline

•             obtain a serum potassium level

•             administer the client’s usual dose of insulin

•             assess pupillary response to light

•             Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance.

•             A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication?

•             increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure

•             the antagonistic interaction among the various blood pressure medications has reduced their effectiveness

•             The additive effect of multiple medications has caused the blood pressure to drop too low

•             the synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension

•             Which client is at the greatest risk for developing delirium?

•             An adult client who cannot sleep due to constant pain.

•             an older client who attempted 1 month ago

•             a young adult who takes antipsychotic medications twice a day

•             a middle-aged woman who uses a tank for supplemental oxygen

•             Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?

•             Reduce risks factors for infection

•             Administer high flow oxygen during sleep

•             Limit fluid intake to reduce secretions

•             Use diaphragmatic breathing to achieve better exhalation

•             Which location should the nurse choose as the best for beginning a screening program for hypothyroidism?

•             A business and professional women’s group.

•             An African-American senior citizens center

•             A daycare center in a Hispanic neighborhood

•             An after-school center for Native-American teens

•             A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling “very tired”. Which nursing intervention is most important for the nurse to implement?

•             Measure vital signs

•             Auscultate breath sounds

•             Palpate the abdomen

•             Observe the skin for bruising

•             A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider?

•             capillary glucose

•             urine specific gravity

•             Serum calcium

•             white blood cell count

•             What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

•             working together can decrease the risk for back injury

•             The technique is intended to maintain straight spinal alignment.

•             Using two or three people increases client safety.

•             turning instead of pulling reduces the likelihood of skin damage

•             A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

•             Which action should the school nurse take first when conducting a screening for scoliosis?

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•             An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement?

•             After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client’s discharge plan?

•             A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

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•             The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication’s effectiveness, which laboratory values should the nurse monitor? Select all that apply

•             A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement?

•             Negative pressure environment

•             contact precautions

•             droplet precautions

•             protective environment

•             A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?

•             A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

•             A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs

•             Which instruction should the nurse provide a pregnant client who is complaining of heartburn?

•             A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

•             Hypokalemia

•             Ketonuria.

•             Peripheral edema

•             Elevated blood pres…