PN Nursing_knowledge_Assessment_Practice_Exam V4 EXIT EXAM Latest Solutions 2022

PN HESI V4 EXIT EXAM Latest Solutions 2022 PN HESI V4 EXIT EXAM Latest Solutions ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) USE (CTRL + F) to search you question (answered) This is the ulti ...

PN HESI V4 EXIT EXAM Latest Solutions 2022 PN HESI V4 EXIT EXAM Latest Solutions ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) USE (CTRL + F) to search you question (answered) This is the ultimate Distinction exam Help ever !! 2022 HESI PN V4 EXIT EXAM 110 QUESTION AND ANSWER(S) Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? Correct Answer: Review with the client the need to avoid foods that are rich in milk and cream A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? Correct Answer: Stroke secondary to hemorrhage The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? Correct Answer: Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? Correct Answer: Describes life without purpose A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan? Correct Answer: Further evaluation involving surgery may be needed A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? Correct Answer: Teach tracheal suctioning techniques In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement? Correct Answer: Document the assessment data — Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory rate is within normal limits. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? Correct Answer: Respiratory apnea of 30 seconds During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? Correct Answer: Check the client for lacerations or fractures At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? Correct Answer: Inform the anesthesia care provider After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? Correct Answer: Listen with the bell at the same location A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? Correct Answer: Medicare A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? Correct Answer: Toasted wheat bread and jelly Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? Correct Answer: "I have a headache that gets worse when I sit up" An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? Correct Answer: Obtain a clean catch mid-stream specimen The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child? Correct Answer: Foods sweetened with aspartame Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? Correct Answer: Direct the nurse to continue the surgical hand scrub for a 5 minute duration Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis? Correct Answer: Bagel with jelly and skim milk The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? Correct Answer: An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? Correct Answer: Cleanse the foot with soap and water and apply an antibiotic ointment The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide? Correct Answer: Stop using the ointment and encourage complete drying of the feet and wearing clean socks. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences Correct Answer: Palpitations and shortness of breath A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? Correct Answer: Obtain a list of medications taken for cardiac history The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) Correct Answer: - Fluid shifts from intravascular to interstitial area due to decreased serum protein - Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen - Increased circulating aldosterone levels that increase sodium and water retention The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) Correct Answer: Murmur — Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence created by the heart or valvular defect. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? Correct Answer: Auscultate the client's bowel sounds Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? Correct Answer: Ask the client to discuss "do not resuscitate" with her healthcare provider A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? Correct Answer: Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? Correct Answer: Have you noticed any changes in your fingernails? — Rationale: The pattern of reported manifestations is suggestive of hypothyroidism After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? Correct Answer: Capillary refill of 8 seconds After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse's signature on the client's surgical consent form? (Select all that apply) Correct Answer: - The client voluntarily grants permission for the procedure to be done - The client is competent to sign the consent without impairment of judgment - The client understands the risks and benefits associated with the procedure Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? Correct Answer: Advise the client that assignments are not based on clients requests A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? Correct Answer: Place the implant in a lead container using long-handled forceps The client with which type of wound is most likely to need immediate intervention by the nurse? Correct Answer: Laceration — Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care? Correct Answer: Monitor blood pressure frequently — Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Although pheochromocytoma has classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified as sites of mutations leading to pheochromocytoma. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? Correct Answer: To reduce abdominal pressure on the diaphragm — Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? Correct Answer: The gallbladder is normal Rationale: a normal healthy gallbladder is not palpable A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? Correct Answer: Inform her that some antianxiety medications are safe to take while breastfeeding Rationale: there are several antianxiety medications that are not contraindicated for breastfeeding mothers. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? Correct Answer: Start an intravenous (IV) infusion of normal saline Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication? Correct Answer: The additive effect of multiple medications has caused the blood pressure to drop too low Which client is at the greatest risk for developing delirium? Correct Answer: An adult client who cannot sleep due to constant pain. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? Correct Answer: Reduce risks factors for infection Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? Correct Answer: A business and professional women's group. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement? Correct Answer: Measure vital signs A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? Correct Answer: Serum calcium What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? Correct Answer: The technique is intended to maintain straight spinal alignment. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client? Correct Answer: Baked apples topped with dried raisins Which action should the school nurse take first when conducting a screening for scoliosis? Correct Answer: Inspect for symmetrical shoulder height. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/minutes. What action should the charge nurse implement? Correct Answer: Assign a practical nurse (LPN) to determine if an apical radial deficit is present After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan? Correct Answer: Encourage a low-carbohydrate and high-protein diet A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform? Correct Answer: Observe the antecubital fossa for inflammation.