Hesi Exit Exam _Answered

Hesi Exit Exam ?? 2021/2022_Answered A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for eight hours, how many ml of full strength feeding will the nurse ...

Hesi Exit Exam ?? 2021/2022_Answered A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value only.) An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? 3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement? UAP using a hand sanitzers that is alcohol for 2 minutes 5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The child weighs 44 pounds. How many mg of the medication should the nurse administer 6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather than trickles from the vagina. The uterine fundus is firm and the client's vital signs are pulse 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take next? A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye. Which action should the school nurse take? Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of "Altered thought processes, secondary to" what condition? The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual cramps" for a 25-year-old female client. Which self-care activity should the nurse emphasize in the client's teaching plan? Psych/Alcohol/Tylenol overdose antidote Medical Surgical/Laxative abuses Spiritual/Documentation Leadership- Interpreter informed consent Geriatrics/Emergency Rib fractures fall A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client's family? Upon assessment, the nurse discovers that a postpartum client has persistent red lochia. Which of the following does this assessment finding suggest to the nurse? The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is drained. What action should the nurse complete first? After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.; Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000. What should the nurse implement? Triage question with a train wreck The psychiatric nurse is called to a train derailment that was likely caused by a terrorist bomb. In triaging those in need of immediate care, what is the priority ranking for these cases? (arrange these cases in order or priority with the top item requiring the most immediate care and the bottom item requiring the least priority care) A crying child being held by another passenger. A woman sitting on the ground with a blanket. A middle-aged man who is wandering around (arrange in order) = middle age woman bleeding- woman w/ blanket- child crying- mother and father. (Mine didn't have a middle age woman bleeding, instead it had an old man wandering and The nurse in the emergency department is using the simple triage and rapid transport (START) system to assess victims of a hurricane. Which statement correctly describes a yellow disaster tag?. What makes a baby frontal bulge or rises Which of the following is a nursing intervention for a 3-year-old client who is going in for sugery in 8 hours that has an order for fluid restriction? The ear, where do u pull to give a ear drop Know your serum levels? When to use drug for motion sickness drug question Pt with DM Electrical burn pt Which discharge instruction has the greatest priority for the mother of a 6-year-old who was diagnosed with Type 1 diabetes mellitus one week ago? A nurse working on a mental health unit where a diagnosis of bulimia nervosa is being admitted. Which of the following symptoms would the nurse most likely NOT expect to find with this client? The charge nurse is developing the nursing guidelines for a coronary care unit. Which references is likely to be the most useful in developing these guidelines? Which assessment finding indicates a client's readiness to leave the nursing unit for a Bronchoscopy? A nurse-manager is preparing an annual budget for the unit. Nursing salaries should be included in which component of the budget? The nurse has not finished administering routine oral medication because on e client experienced chest pain and another rectal bleeding. It is now dinner time and two clients must be fed. The unlicensed assistive personnel (UAP) is filling water pitchers and the practical nurse (PN) is charting vital signs. Which change in assignments is best for the team leader to make? What is manntiol drug used for? The nurse is caring for a 42 year old male client who is excreting less sodium than he is consuming. If this condition continues, what complication can the nurse expect this client to exhibit? A 40-year-old client with type 1 diabetes developed chronic kidney (CKD) disease 6 months ago. Because of secondary complications often associated with this illness the nurse plans to carefully assess for signs of what condition? A pt on a trachea/endotrach with gurgling sound Know how the chest tube vac machine works - there is a picture of a chest tube vac machine. Child w/ hemophila You are preparing a plan of care for a client who is a Jehovah's Witness.The client has been told that surgery is necessary. With consideration to the client's religious preferences in development of the plan of care, you would document what? A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely for what? A 68-year-old male has been admitted to the hospital with abdominal pain, anemia and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. Nurse writes on the chart of Bob Miller that his nurse, Nurse Smith did not take great care of Mr. Miller. Nurse Jones has committed which of the following? A client is prescribed Zolpidem (Ambien). Which of the following side effects should be monitored while the client is taking this medication? Translator is working with the nurse who is giving discharge instructions to a non-English client. When the translator restates what the nurse is saying it appears that he is saying much more than what the nurse said. What action should the nurse take? Who is at risk for rib fracture Splint Metabolic syndrome - high cholesterol & Know how to prevent SIDS death Hypertension Diet Teaching- presented with a list of menu choices, the best choice was Teenager attempted suicide and during group session became upset and left group Client has rapid speech, flight of ideas, 3hrs of sleep New RN to Unit Incorrect Delegation While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? One week after client received above the knee amputation, client experiences phantom pain in left foot, what to do The nurse-manager of a perinatal units is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit? Decerebrate Positioning Four clients arrive at the labor and delivery nurses' station at the same time. Which pt should the nurse assess first? Teenagers Teaching for Diabetic diet Pyelonephritis symptoms Leg cast Assessment Diagnosis of breast cancer Risk Osteoarthritis Client skin integrity for client with chronic venous insufficiency IV Line Teaching Nurse given a change in drug orders via phone from physician for a client headed to radiology, place in order what steps the nurse should take first to last? Heparin When the nurse auscultates the anterior chest just above the right nipple moderate, pitched breath sounds are heard that are equal on inspiration and expiration. Which statement best describes this finding? Priority pt Magnesium Endotrach has slipped into right main bronchus of no breath sounds are heard (Audio/Visual) Chron's disease Dialysis Acute Pancreatitis 39 to 48 Glucose Ankle brachial index Anterior Cruciate Ligament injury Select all that apply) Mantoux test Late decelerations Crohn's Disease - Which has lowest Na+- choose Disseminated intravascular coagulation (DIC) : Septic shock-best class of medicine to give are Adolescents and drug abuse at 13yrs old- A female client who has been taking the corticosteroid methylprenisolone (Solu-Medrol) for three weeks reports to the nurse that she has gained ten pounds since starting the medication, and she wants to stop taking it. What is the best response by the nurse? In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse? A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye. Which action should the school nurse take? A nurse who is new to the pediatric unit is positioning a 6 month-old for an injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action should the nurse-manager who is supervising this nurse take first? After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child's mother indicates that she understands home care treatment to promote pulmonary function? Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of "Altered thought processes, secondary to" what condition? The nurse is caring for a client who was admitted two hours ago with confusion, Kussmaul respirations, and warm, flushed skin. The healthcare provider determines the client is in acute renal failure (ARF). Which intervention is most important for the nurse to include in this clients plan of care? The nurse observes a 2cm area of non-blanchable erythema on the sacrum of an immobile client. What documentation of this finding is best for the nurse to enter into the client's record? A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client's family? A 14-year-old male client arrives at the emergency room in status epilepticus. He was diagnosed with a seizure disorder in childhood. What is the most likely cause of his present condition? A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? The nurse is teaching a childbirth education class t prospective parents and describing possible signs of labor. Class participants should be taught that which sign should be reported to the healthcare provider immediately? During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir (Zovirax) prior to this pregnancy tells the nurse that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority? . The nurse is obtaining a medication history for a client with a new prescription for paroxetine (Paxil). The client reports current use of the MAO inhibitor isocarboxazid (Marplan). What intervention is most important for the nurse to implement? After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? What action should the nurse implement first when delegating nursing activities to an unlicensed assistive personnel (UAP)? The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.; Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000. What should the nurse implement?. A 40-year-old client with type 1 diabetes developed chronic kidney (CKD) disease 6 months ago. Because of secondary complications often associated with this illness the nurse plans to carefully assess for signs of what condition? A client diagnosed with acute epididymitis secondary to a sexually transmitted disease receives a prescription for ceftriaxone (Rocephin). Prior to administering the prescription, which question should the nurse ask the client? A client at 38 weeks gestation is in active labor, and a vaginal birth after Cesarean section (VBAC) is planned. Vaginal exam indicates that the client is 6cm dilated, 90% effaced, and the station 0 with intact membranes. As the client's contraction become stronger, the fetal heart rate decelerates during the contraction but returns to baseline. What action should be taken? An elderly client with limited mobility reports frequent episodes of nocturia. To reduce the risk for urinary incontinence, what action should the nurse implement? Which diagnosis tests are most important for the nurse to monitor when providing care for a client with a bowel movement? While assessing a client with wrist restraints the nurse first slides two fingers under the restraints and then notes that the ties are secured to the side rail using a quick-release tie. What action should the nurse implement? After administering the first dose of newly prescribed medications to four clients within a thirty minute time frame, the nurse evaluates each client for therapeutic responses or any adverse reactions. Which medication should the nurse evaluate first? What is the most important symptom the nurse should monitor the client for while assisting with the insertion of a subclavian central venous catheter? A client admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test? The nurse is performing an intake interview at a prenatal clinic. Which planned activities described by the client who is at 6 weeks gestations will the nurse investigate first? The nurse notes that a postoperative adult client's respiratory rate is 10 breaths/minute. Which factor in the client's history is the most likely explanation for this finding? The nurse is assessing a client with hypothyroidism and knows that these clients are at risk for myxedema coma. What symptoms indicate that the client is developing this condition? While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother's vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first? The nurse-manager of a perinatal units is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit? The nurse is assessing a client with hypothyroidism and knows that these clients are at risk for myxedema coma. What symptoms indicate that the client is developing this condition? A client is receiving a continuous infusion of normal saline at 125ml per hour. The nurse prepares to change the primary IV tubing and hang a new bag of normal saline to maintain the prescription. In which sequence should the nurse implement the procedure? A client who is wheelchair-bound demonstrates a positive Thomas test after admission to the rehabilitation unit. The health care provider prescribes positioning the client prone for 30minutes three times each day to prevent further contractures. Based on this finding, what change in the client's plan of care should the nurse expect? While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? A client with a general anxiety disorder is pacing the hallway. The client tells the nurse, "My heart is just racing and sometimes it feels like it's fluttering. I'm feeling short of breath and dizzy." What action should the nurse implement first? . Translator is working with the nurse who is giving discharge instructions to a non-English client. When the translator restates what the nurse is saying it appears that he is saying much more than what the nurse said. What action should the nurse take? An Elderly man is having trouble urinating and unsteady he uses a wheelchair to walk to the bathroom what should the nurse implement? The nurse tests a client's visual acuity and determines that the uncorrected vision is 20/100 in the right eye and 20/80 in the left eye. What does this finding indicate? Client has a Lithium Rx level of 0.54 (know Lithium ranges (Select all that apply) Determining pain level for 3mo old infant 5yr old burn victim has pot of hot liquid fall on him, what should nurse tell mother to do first- The Nurse recognizes that the primary purpose of recommending a yearly digital rectal examination (DRE) for all men over the age of 40 is to help detect the early stages of which type of cancer? A client with carpal tunnel syndrome is in the out-patient surgical unit after an endoscopic carpal tunnel release. What instructions should the nurse provide the client regarding postoperative care? Which client should the nurse assist first? A client with a chest tube develops sepsis and dyspnea. Based on findings in the client's medical record, which prescription should the nurse implement first? The nurse is teaching a client with COPD about health promotioin activities. What is the most important advice the nurse should give this client? A client at 38-weeks gestation complains of abdominal pain. The nurse notes that her abdomen is rigid. What is the probable cause of these findings? Family members of a client who is in hospice care discuss with the nurse their fears that their loved one's death will be painful. Which intervention should the nurse implement? Which nurse's behavior is a breach of clients confidentiality according to the Health Insurance Portable Accountability Act (HIPAA) regulations? A male client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescription include radiation therapy. What action should the nurse implement? An Elderly man is having trouble urinating and unsteady he uses a wheelchair to walk to the bathroom what should the nurse implement? The nurse completes the Leopold maneuvers for a primipara who is admitted in active labor and determines that the fetus is in the right sacral anterior (RSA) position. On which quadrant should the nurse place the external fetal heart transducer? The nurse is caring for a 5 year-old child with Reye's syndrome. What goal has the highest priority in caring for this child? The nurse is preparing a discharge plan for an older client who was recently diagnosed with Alzheimer's disease. Which intervention should the nurse suggest to the spouse if the client becomes uncooperative at home? A mother brings her 15-month old son and 6 year-old daughter to the clinic for immunizations. Both children are fretful and obviously have upper respiratory infections. The mother tells the nurse that the younger child ran a fever of 100.2oF following his last immunization. What plan is best for the nurse to implement? Pregnancy Induced Hypertension A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator. What action should the nurse implement? A client who has localized eczematous eruptions on both hands is diagnosed as having contact dermatitis. What instructions should the nurse include on the clients discharge teaching plan? The community health nurse is attempting to address the issue of child abuse in a large metropolitan area. A primary prevention program for child abuse might include which program?. Risk management: pt fell while using some equipment... charge nurse trying to find out what happened- how? A client has a history of chronic atrial fibrillation. Which instruction should the nurse include in the teaching plan for this client? Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother's vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first? It is most important for the nurse to use an IV pump and/or Buretrol, an in-line volumecontrol device, when initiating IV therapy for a client following which surgical procedure?. . Which strategy is most important for the nurse to use when assisting a client with myasthenia gravis to devise a daily routine? A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per min. Which drug is the transport team most likely to administer to the infant? A 60 year-old female client takes NPH insulin each morning. What would necessitate holding this clients usual morning NPH insulin dose? Which finding should the nurse expect a client to exhibit who is newly diagnosed with fibromyalgia? Chest tube disconnect :