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HESI Exit Exam

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A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain? A. The client's usual sleeping pattern B. Whether the client smokes C. How... much liquid the client consumes before bedtime D. The amount of caffeine that the client consumes during the day Rationale: The first thing to determine is the client's usual sleeping pattern and how it has changed to become what the client describes as insomnia. Options B, C, and D provide additional information after option A is ascertained. 2. A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? A. The respiratory settings on the ventilator B. Only the client's spontaneous respirations C. The ventilator-assisted respirations minus the client's independent breaths D. The ventilator setting for respiratory rate and the client-initiated respirations Rationale: The nurse should count the client's respirations and document both the respiratory rate set by the ventilator and the client's independent respiratory rate. Never rely strictly on option A. Although the client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture of the client. 3. Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention should the nurse implement based on these results? A. Increase the oxygen flow rate from 4 to 10 L/min per nasal ca [Show More]

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