HESI EXIT EXAM 2019 Version 3 | Questions and Answers | 100 % Correct
1. While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin-resistant Staphylo
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HESI EXIT EXAM 2019 Version 3 | Questions and Answers | 100 % Correct
1. While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin-resistant Staphylococcus aureus (MRSA). To reduce the risk of recurrence of the MRSA in the postoperative wound, which intervention is most important for the nurse to implement?
A. Report any increase in the white blood count.
B. Change the surgical dressing readily when soiled.
C. Wear a face mask while performing wound care.
D. Instruct the family to adhere to contact precautions.
ANS: D
2. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement?
A. Replace the IV site with a smaller gauge.
B. Redress the abdominal incision
C. Leave the lights on in the room at night.
D. Apply soft bilateral wrist restraints.
ANS: B
3. When caring for an older male client with urinary frequency, which measure is most important for the nurse to implement to help the client prepare to go to bed for the night?
A. Offer the client an evening snack before providing oral care.
B. Place fresh water and a glass within reach on the bedside table.
C. Ensure that the call bell is easily accessible to the client.
D. Reassure the client someone will check on him hourly.
ANS: C
4.When obtaining a throat culture from a 6-year-old with possible streptococcal infection, which action is most important for the nurse to implement?
A. Encourage the parent to hold their child during the procedure.
B. Instruct the child to look at the ceiling and open mouth widely.
C. Allow the child to hold the tongue depressor and practice saying “Ah”
D. Swab the child’s erythematous oropharyngeal surfaces or tonsillar pustules.
ANS: D
5. During a return demonstration of teaching provided by the nurse, the daughter of a client administers the mother’s eye drops by resting her dominant hand on her mother’s forehead and dropping the medication into the conjunctival sac. Which action should the nurse take in response to this demonstration?
A. Remind the client to gently close her eyes after the eye drops are instilled.
B. Instruct the mother to gently rub the affected eye to distribute the drops.
C. Advice the daughter to keep her hand farther from her mother’s eye.
D. Offer to demonstrate the eye drop procedure to the daughter one more time.
ANS: D
6. An older adult client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which interventions should the nurse implement first? (Please scroll and view each tab’s information in the client’s medical record before selecting the answer.)
Flow Sheets
Vital Signs
Heart Rate – beats/minute 110
Respirations – breaths/minute 28
Blood Pressure – mmHG 80/60
Laboratory
Electrolytes
Sodium – 1.30 mEq/L
Potassium – 2.5 mEq/L
Chloride – 95 mEq/L
Diagnostics
Arterial blood gases (ABGs)
pH – 7.34
PaCO2 – 34 mmHg
HCO3 - 20 mEq/L
po2 – 90 mmHg
A. Initiate continuous dopamine infusion at2 mcg/kg/minute.
B. Give bolus of 0.9% sodium chloride 1,000 ml over 30 minutes.
C. Administer promethazine 2.5 mg slowly IV push q4.
D. Begin potassium chloride 10 mEq over 1 hour per secondary infusion.
ANS: B
7. The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which interventions should the nurse implement?
A. Initiate open communication with the teen’s parents.
B. Talk directly to the adolescent while providing care.
C. Inquire about food allergies and food likes and dislikes.
D. Monitor vital signs and neuro status every 2 hours.
ANS: B
8. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client’s plan of care?
A. Monitor the client’s cardiac activity via telemetry.
B. Maintain venous access with an infusion of normal saline.
C. Assess glucose via fingerstick q4 to 6 hours.
D. Evaluate hourly urine output for return of normal renal function.
ANS: A
9. A middle aged male client, admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident, is currently in stable condition. Based on this client’s age and recent life-threatening crisis, which intervention is should the nurse implement?
A. Allow long periods of uninterrupted rest in order to reduce fatigue.
B. Encourage the client to reflect on personal goals and priorities.
C. Provide a routine schedule of activities to fascinate trust.
D. Discuss the cause of the accident with the client and his family.
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