PN HESI EXIT EXAM V1

PN Hesi Exit V1 Question 1 A school-age client with diabetes is placed on an intermediateacting insulin and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. ...

PN Hesi Exit V1 Question 1 A school-age client with diabetes is placed on an intermediateacting insulin and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. What does the nurse tell the client the snack is intended to do? You Selected: • Prevent late night hypoglycemia. Correct response: • Prevent late night hypoglycemia. Question 2 A well-known public official of a small community is admitted to the emergency department following an episode of chest pain. Several nurses from the medical unit are aware of the admission and access the official’s electronic medical record to obtain a status update. What is the best response for the nurse manager to make to the nurses regarding this situation? You Selected: • “Assessing the official’s medical record is a breach of confidentiality.” Correct response: • “Assessing the official’s medical record is a breach of confidentiality.” Question 3 A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell (WBC) count, especially the neutrophil count, is low. What is the most important intervention the nurse should teach the parents? You Selected: • Protect your child from infections because his resistance to infection is decreased Correct response: • Protect your child from infections because his resistance to infection is decreased Question 4 The nurse is caring for a client with influenza. The most effective way to decrease the spread of microorganisms is: You Selected: • placing the client in isolation. Correct response: • washing the hands frequently. Question 5 A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure? You Selected: • in the supine, sitting, and standing positions Correct response: • in the supine, sitting, and standing positions Question 6 A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further? You Selected: • cool, pale fingers Correct response: • cool, pale fingers Question 7 A nurse is caring for a female client before surgery. The client states that she is glad that she will not be going through menopause as a result of her surgery and is only having her uterus removed. The nurse reviews the consent form and notes that the surgery is for a total abdominal hysterectomy with a salpingo-oophorectomy. What should the nurse do in this situation? You Selected: • Contact the surgeon to explain that the client needs further clarification regarding surgery. Correct response: • Contact the surgeon to explain that the client needs further clarification regarding surgery. Question 8 A young client diagnosed with schizophrenia is talking with the nurse and says, "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I would like to get out and do things again." What is the best initial response by the nurse? You Selected: • "What activities did you enjoy in the past?" Correct response: • "What activities did you enjoy in the past?" Question 9 A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia? You Selected: • nausea, vomiting, and anorexia Correct response: • dyspnea, tachycardia, and pallor Question 10 The nurse is discontinuing an intravenous catheter on a 10-year-old client with hemophilia. What would be the most important intervention for this client? You Selected: • Apply firm pressure on the site for 5 minutes after removal. Correct response: • Apply firm pressure on the site for 5 minutes after removal. Question 11 When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse’s priority assessment? You Selected: • checking the dressing, drain, and amount of drainage Correct response: • assessing the vital signs and oxygen saturation levels Question 12 A client with an uncomplicated term pregnancy arrives at the laborand-delivery unit in early labor saying that she thinks her water has broken. What is the nurse’s best action? You Selected: • Ask what time this happened and note the color, amount, and odor of the fluid. Correct response: • Ask what time this happened and note the color, amount, and odor of the fluid. Question 13 When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes You Selected: • ensuring the abbreviations are understandable to clients who may seek access to their health records Correct response: • limiting abbreviations to those approved for use by the institution Question 14 During routine prenatal screening, a nurse tells a client that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates? You Selected: • "This screening indicates if your baby's lungs are mature." Correct response: • "This test will screen for spina bifida, Down syndrome, or other genetic defects." Question 15 A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? You Selected: • chicken and orange slices Correct response: • chicken and orange slices Question 16 A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse? You Selected: • Collaborate with the interprofessional team to make a referral to social services. Correct response: • Collaborate with the interprofessional team to make a referral to social services. Question 17 A client is newly diagnosed with asthma. While learning to use a metered dose inhaler (MDI) for delivery of a short-term beta agonist, the client asks if a spacer is appropriate to use with this device. What is the nurse’s best response? You Selected: • “No, a spacer is not recommended because it can increase the risk of developing oropharyngeal candidiasis.” Correct response: • “Yes, a spacer is recommended because it increases the amount of medication that is delivered to the lungs.” Question 18 The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client’s pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client’s vital signs, and the client’s score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. What should the nurse do next? You Selected: • Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed. Correct response: • Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed. Question 19 The nurse is making a room assignment for a client whose laboratory test result indicate pancytopenia. Which client should the nurse put into the same room with the client with pancytopenia? You Selected: • a client with digoxin toxicity Correct response: • a client with digoxin toxicity Question 20 A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which of the following? You Selected: • A referral. Correct response: • A referral. Question 21 A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first? You Selected: • the client admitted after a head injury in a motor vehicle who reports nausea Correct response: • the client admitted after a head injury in a motor vehicle who reports nausea Question 22 The mother of an adolescent client who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which response by the nurse is appropriate? You Selected: • “Tell me what you’ve found in your reading that’s leading you to that conclusion.” Correct response: • “Tell me what you’ve found in your reading that’s leading you to that conclusion.” Question 23 A nurse prepares a client's medication by reconstituting a multi-dose vial of medication. What other nursing interventions should the nurse take? Select all that apply. You Selected: • Label the vial with the strength of the medication. • Store the multi-dose vial in a secure place. • Initial the vial as the person reconstituting the medication. Correct response: • Label the vial with the strength of the medication. • Store the multi-dose vial in a secure place. • Initial the vial as the person reconstituting the medication. Question 24 Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next: You Selected: • discuss the situation and possible courses of action with the dietitian and the client. Correct response: • discuss the situation and possible courses of action with the dietitian and the client. Question 25 After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the mother agrees to seek medical advice if the child experiences which symptom? You Selected: • fussiness and reports that the cast is heavy Correct response: • inability to extend the fingers on the right hand Question 26 While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at the nurse's clinic. What is the nurse's most appropriate response? You Selected: • "I'm sorry, I can't disclose client information." Correct response: • "I'm sorry, I can't disclose client information." Question 27 When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication? You Selected: • urinary retention Correct response: • urinary retention Question 28 Which situation demonstrates correct principles of confidentiality? You Selected: • Two nurses alone in an elevator are discussing a client's status. Correct response: • An emergency department nurse reports suspected child abuse. Question 29 The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, “Why? Everything was going well. How could they do this to me?” What response by the staff nurse reflects an understanding of the client’s borderline disorder? You Selected: • “Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety.” Correct response: • “Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety.” Question 30 A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is: You Selected: • monitoring the blood glucose level closely. Correct response: • monitoring the blood glucose level closely. Question 31 A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse? You Selected: • “The drainage is an indication that the sutures were not tight enough.” Correct response: • “If a wound heals on the surface but infection remains, it will open and drain.” Question 32 A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next? You Selected: • Instruct the client to use a pant-blow pattern of breathing. Correct response: • Instruct the client to use a pant-blow pattern of breathing. Question 33 A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it You Selected: • may induce bronchospasm. Correct response: • may induce bronchospasm. Question 34 Bone resorption is a possible complication of Cushing’s disease. To help the client prevent this complication, what should the nurse recommend to the client? You Selected: • Maintain a regular program of weight-bearing exercise. Correct response: • Maintain a regular program of weight-bearing exercise. Question 35 A client rates the pain level of a migraine an 8 on a scale of 1-10. How would the nurse administer the medication to give the client the quickest relief? You Selected: • intravenous (IV) Correct response: • intravenous (IV) Question 36 A client with Parkinson’s disease w