EXIT HESI 2022 Answered Already Graded A

EXIT HESI 2022 Answered Already Graded A. An older client's daughter calls the home health nurse and reports that her mother has become and is very confused at night. The daughter states that her mother's behavior change ...

EXIT HESI 2022 Answered Already Graded A. An older client's daughter calls the home health nurse and reports that her mother has become and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days 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. b. Encourage increase intake of high protein foods. c. Instruct the daughter to check her mother's temperature. d. Review the clients current food and medication allergies. e. Determine if the mother has recently experienced a fall. 1.The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis, which expected outcome has the highest priority. a. Identifies 2 treatments for Constipation due to immobility. b. Names three home safety hazards to be resolved immediately. c. States 4 risk factors for the development of osteoporosis. d. List five calcium rich foods to be added to her daily diet. 1. The nurse preparing a client who had a BKA ( below the knee amp) for discharge to home. Which recommendations should the nurse provide this client? (SATA) a. Avoid range of motion exercises b. Use residual limb shrinker c. Wash the stump with soap and water d. Inspect skin for redness e. Apply alcohol to the stump after bathing A client's morning assessment includes bounding peripheral pulses, weight gain of 2lbs (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care? a. Restrict daily fluid intake to 1500 mL b. Administer prescribed diuretic c. Maintain accurate intake and output d. Weigh client every morning 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 B. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting C. Assess the client's mucous membranes and report the findings to the HCP D. Advice the client to replace cooked foods with a variety of different nutritional supplements 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? A. administer hypertonic IV fluids as prescribed B. Limit fluid Intake Assess neurological status every 8 hours Initiate seizure precautions 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? a. distended tortuous veins in the left hand b. auscultation of the thrill in the left forearm c. the left radial pulse is 2+ bounding d. assessment of bruit on the left forearm An older client arrives to the emergency department (ED) with reports of sever nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature 95.4 (35.2), heart rate 112 beats/min, respirations 14 breaths/minute, and blood pressure 74/37 mmHg. Which intervention is most important for the nurse to implement? a. Maintain Strict intake and output b. monitor blood glucose level c. keep head of bed raised 45 degrees d. assess warmth of extremities The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply a. Avoid prolonged standing or sitting b. Use recliner for long period of sitting c. continue wearing elastic stocking d. Maintain the bed flat while sleeping e. Cross legs at knee but not at ankle 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 b. Cheddar cheese cubes c. slightly salted potato chips d. plain, air popped popcorn e. canned fruit in heavy syrup The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? a. aerobic exercise b. weight bearing exercise c. muscle stretching and toning d. core strengthening A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse? a. Low-grade fever, headache, and malaise for the past 72 hours b. Unable to bear weight on the left foot, with the swelling and bruising c. Chest discomfort one hour after consuming a large, spicy meal d. One-inch bleeding laceration on the chain of the crying five-year-old An adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply a. History of hypertension. b. Homosexual lifestyle c. Vegetarian diet d. Excessive aerobic exercise A nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? SATA. a. Leans forward to pull from the high shelf b. bends from the waist to pick trash off the floor c. locks knees while preparing food on the counter d. brings the heavy can close to body before lifting e. Widens stance while working near the sink. The nurse is feeding a client who was admitted this morning with syncope and generalized weakness. The client has a history of aspiration and begins coughing while attempting to drink through a straw. Which action should the nurse implement? a. Elevate head of bed for 30 minutes after meals. b. Perform oral care before meals. c. Allow small amount of liquids with meals. d. Provide nectar thickened liquids After receiving report on an inpatient acute care unit, which client should the nurse assess first? a. the client with a small bowel obstruction who has a nasogastric tube that is draining green fluid b. the client with a bowel obstruction due to a volvulus who is experiencing abnormal rigidity c. the client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds d. the client with an obstruction of the large intestine who is experiencing abdominal distention. A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? a. Allopurinol (Zyloprim) b. Aspirin, low dose c. Furosemide (lasix) d. Enalapril (vasote) A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax? a. Continuous bubbling in the water seal chamber b. Decrease bright red blood drainage c. Tachypnea and difficulty breathing d. Tracheal deviation toward the left lung A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care? a. Fingerstick glucose assessment q6h with meals b. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose c. Review with the client proper foot care and prevention of injury d. Do not contaminate the insulin aspart so that it is available for iv use e. Coordinate carbohydrate controlled meals at consistent times and intervals f. Teach subcutaneous injection technique, site rotation and insulin management A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? a. Instructions about how much fluid the child should drink daily b. information about non-pharmaceutical pain reliever measures c. Referral for social services for the child and family d. Signs of addiction to opioid and medications The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended? a. Hold the client at arm's length while transferring to better distribute the body weight. b. Apply the gait belt around the client's waits once standing position has been assumed. c. Place a client's locked wheelchair on the client's strong side next to the bed. d. Pull the client into position by reaching from the opposite side of the bed. A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse? a. Low-grade fever, headache, and malaise for the past 72 hours b. Unable to bear weight on the left foot, with the swelling and bruising c. Chest discomfort one hour after consuming a large, spicy meal d. One-inch bleeding laceration on the chain of the crying five-year-old A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? a. Does she know the person who raped her? b. Has she taken a bath since the raped occurred? c. Is the place where she lived a safe place? d. Did she report the rape to the police Department? A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull gnawing pain that is relieved when he eats. What is the best response by the nurse? a. Encourage the client to obtain a complete physical exam since the symptoms are consistent with an ulcer. b. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food c. Instruct the client that these mild symptoms can generally be controlled with changes in his diet. d. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? a. "when I get out of bed quickly, I feel a little dizzy." b. "the dressing over my incision feels like it is too tight" c. "I'm most comfortable when the head of the bed is raised." d. "This IV infusion makes me urinate more often than usual." Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? a. Reduce risks factors for infection b. Administer high flow oxygen during sleep c. Limit fluid intake to reduce secretions d. Use diaphragmatic breathing to achieve better exhalation An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? a. Limit the intake of high calorie foods. b. Eat meals at the same time daily. c. Maintain a low protein diet. d. Restrict daily fluid intake. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? (Select all that apply.) a. Lentils b. Potato soup c. Tea d. Cheese The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? a. Convey to the client that birth is imminent. b. Prepare the client for spinal anesthesia c. Empty the client's bladder using a straight catheter d. Prepare the coach to accompany the client to delivery A psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention? a. 16-year-old client diagnosed with major depression who refuses to participate in group b. a 14-year-old client with anorexia nervosa who is refusing to eat the evening snack c. an 18-year-old with antisocial behavior who is being yelled at by other clients d. a 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) a. Monitor abdominal girth. b. Increase oral fluid intake to 1500 ml daily. c. Report serum albumin and globulin levels. d. Provide diet low in phosphorous. e. Note signs of swelling and edema. Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome? a. Avoid exposure to respiratory infections. b. Use relaxation exercise when anxious c. Continue physical therapy at home d. Plan short, frequent rest periods. A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral arterial disease. Which question should the nurse ask the client about experienced findings to chronic arterial symptoms? a. Were your legs suddenly swollen, red, warm and painful? b. does the calf pain occur when walking short distances? c. Did you receive treatment for weeping ulcers on lower legs? d. Have you experienced ankle edema and varicose veins? The nurse is caring for a client who has a chronic obstructive pulmonary disease (COPD) and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD? a. Monitoring telemetry and cardiac rhythm Assisting client to cough and deep breath c. Increasing the client's fluid intake d. administering narcotics for pain relief The father of 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? a. Reassure the client that his child will be allowed to visit b. Obtain a detailed report from the nurse transferring the client. c. Mark the chart with client's request for no heroic measured. d.Provide the client whitening information about end-of-life care The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension? a. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie. b. Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie. c. Grilled steak, baked potato with sour cream, green beans, coffee and raisin cream pie. d. Beed stir fry, fried rice, egg drop soup, diet coke and pumpkin pie. When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands they prescribed diet? a. Roasted turkey canned vegetables b. Baked potatoes with skin raw carrots c. Pancakes whole-grain cereal's d. Roast pork fresh strawberries A nurse working on an endocrine unit should see which client first?a. a. An adolescent male with diabetes who is arguing about his insulin dose. b. An older client with Addison's disease whose current blood sugar level is 62mg/dl (3.44 mmol/l). c. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour. d. A client taking corticosteroids who has become disoriented in the last two hours. A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first? a. Assess the client's ability to communicate with the other staff members b. Arrange a meeting with the family to discuss the client's situation c. Administer the client's antidepressant medication as prescribed. d. Establish a structured routine for the client to follow