HESI Exit RN 2021 V 2

The school nurse is preparing a presentation for an elementary school teacher 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 ...

The school nurse is preparing a presentation for an elementary school teacher 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? (Select all that apply) a. Refuses to complete written homework assignments b. Thirst and frequent requests for bathroom breaks c. Bruises on both knees after the weekend d. Sunburn with blisters on face, arms, and hands e. Shaking that changes the child’s handwriting 2. When preparing a child for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client’s discharge teaching plan? a. Report any signs of cloudy urine output b. Frequently empty bladder to avoid distention c. Follow instructions for self-care toileting d. Seek counseling for body image 3. A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic. Which assessment finding should prompt the nurse to administer PRN dose of naloxone? a. Unresponsive to verbal or tactile stimuli b. Respiratory rate of 12 breaths per minute c. Statements about visual hallucinations d. Complaints of increasing flank pain 4. The mother of a 7-month-old brings the infant to the clinic, because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a. Instruct the mother to change the child’s diaper more often b. Encourage the mother to apply lotion with each diaper change c. Ask the mother to decrease the infant’s intake of fruits for 24 hours d. Tell the mother to cleanse with soap and water at each diaper change 5. The nurse is having difficulty palpating a client’s posterior tibial pulse while the client is lying in a supine position. Which of the following interventions is best for the nurse to take? a. Extend the client’s arm fully while supporting the elbow and attempt to repalpate b. Apply less pressure when palpating over the middle of the dorsum of the foot c. Use an ultrasound stethoscope, and place behind and below the medial bone d. Help the client to a prone position with the knee slightly flexed and palpate again 6. The nurse initiates a tertiary prevention program for type 2 diabetes mellitus in a rural health clinic. Which outcome indicates that the program was effective? a. Average client scores improved on specific risk factor knowledge tests b. Only 30% of client did not attend self-management education sessions c. More than 50% of at-risk clients were diagnosed earl in the disease process d. Client who developed disease complications promptly received rehabilitation 7. A client is recovering in the critical care until following a cardia catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complains of pain at the right going insertion site. What action should the nurse implement? a. Stimulate the client to take deep breaths b. Evaluate the integrity of the IV insertion site c. Assess distal lower extremity capillary refill d. Check femoral site for hematoma formation 8. A 7-year old is admitted to the hospital with persistent vomiting, and nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider? a. Shift intake of 640mL IV fluids plus 30mL PO ice chips b. Serum pH of 7.45 c. Serum potassium of 3.0 mg/dl d. Gastric output of 100 mL in the last 8 hours 9. A morbidly obese client is scheduled for gastric bypass surgery. The client completes the required preoperative nutritional counseling and signs the operative permit. To promote effective discharge planning, which intervention is most important for the nurse to implement? a. Discuss small, low fat, low sugar meal preparation techniques b. Advise the client to arrange for dietary counseling after being discharged c. Encourage the client to keep a daily diary for two weeks d. Suggest that the client’s spouse do the family grocery shopping 10. The nurse is admitting a client from the post-anesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first? a. Cefazolin 1-gram IVPB q6 hours b. Complete blood cell count (CBC) in AM c. Straight catheterization if unable to void d. Advance from clear liquid as tolerated 11. Which needle should the nurse use to administer IV fluids via c lient’s implanted port? a. 5cc syringe & needle b. Butterfly stick c. **click on the image that isn’t any of the other options** d. Vacutainer 12. An older client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left-sided paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client’s plan of care? a. Use pictures and gestures to communicate b. Arrange for daily home care assistance c. Facilitate a consultation for speech therapy d. Initiate passive range of motion exercises 13. A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement? a. Assess the client for the presence of hemorrhoids b. Administer a prescribed PRN antiemetic c. Check the client’s hemoglobin level d. Review the client’s current list of medications 14. A mother runs into the emerg