HESI Exit Exam Test Bank

1. Following ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protecthis ulcer. What is the best follow-up action by the nurse? A. Review with the client the need to avo ...

1. Following ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protecthis ulcer. What is the best follow-up action by the nurse? A. Review with the client the need to avoid foods that are rich in milk and cream 2. 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? A. Stroke secondary to hemorrhage 3. 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? A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. 4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? 5. 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? A. Further evaluation involving surgery may be needed 6. 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? A. Teach tracheal suctioning techniques 7. 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? A. Document the assessment data B. Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratory rate is within normal limits. 8. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? A. Respiratory apnea of 30 seconds 9. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? A. Check the client for lacerations or fractures 10.At 0600 while admitting a woman for a schedule repeat cesarean section (CSection), 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? A. Describes life without purpose A. Medicare A. Toasted wheat bread and jelly A. 11.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? A. Listen with the bell at the same location 12.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? 13. 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? 14. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? A. “I have a headache that gets worse when I sit up” B. “I am having pain in my lower back when I move my legs” C. “My throat hurts when I swallow” D. “I feel sick to my stomach and am going to throw up” 15.An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? A. Obtain a clean catch mid-stream specimen 16.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? A. Foods sweetened with aspartame 17.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? 18.Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis? 19. 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)? A. An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied A. Bagel with jelly and skim milk A. Direct the nurse to continue the surgical hand scrub for a 5 minute duration Inform the anesthesia care provider 20. 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? A. Cleanse the foot with soap and water and apply an antibiotic ointment B. Provide teaching about the need for a tetanus booster within the next 72 hours. C. have the mother check the child's temperature q4h for the next 24 hours D. transfer the child to the emergency department to receive a gamma globulin injection 21.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? A. Stop using the ointment and encourage complete drying of the feet and wearing clean socks. 22. 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 A. Bradycardia and constipation B. Lethargy and lack of appetite C. Muscle cramping and dry, flushed skin D. Palpitations and shortness of breath 23.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? A. Obtain a list of medications taken for cardiac history 24.The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) A. 75 B. Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour 25.The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) A. Fluid shifts from intravascular to interstitial area due to decreased serum protein B. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen C. Increased circulating aldosterone levels that increase sodium and water retention 26. 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) B. Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence created by the heart or valvular defect. A. Murmur 27. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth) A. 0.4 B. rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml 28. 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? A. Auscultate the client's bowel sounds B. Observe for edema around the ankles C. Measure the client’s capillary glucose level D. Count the apical and radial pulses simultaneously E. 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 29.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? A. Ask the client to discuss “do not resuscitate” with her healthcare provider 30.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? A. Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour 31.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? A. Have you noticed any changes in your fingernails? B. Rationale: The pattern of reported manifestations is suggestive of hypothyroidism 32.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? B. bruises on arms and legs C. round and tight abdomen D. pitting edema in lower legs 33.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) 34.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? A. The client voluntarily grants permission for the procedure to be done B. The client is competent to sign the consent without impairment of judgment C. The client understands the risks and benefits associated with the procedure A. Capillary refill of 8 seconds A. Advise the client that assignments are not based on clients requests 35.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? 36.The client with which type of wound is most likely to need immediate intervention by the nurse? A. B. Abrasion C. Contusion D. Ulceration E. 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. 37. 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? A. Monitor blood pressure frequently B. Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor thatmay 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. 38. 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? A. To reduce abdominal pressure on the diaphragm B. to promote retraction of the intercostal accessory muscle of respiration C. to promote bronchodilation and effective airway clearance D. to decrease pressure on the medullary center which stimulates breathing E. 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. 39.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? A. The client is too obese B. Palpating in the wrong abdominal quadrant C. Deeper palpation technique is needed D. The gallbladder is normal E. Rationale: a normal healthy gallbladder is not palpable 40. 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 A. Place the implant in a lead container using long-handled forcep Laceration Downloaded by: sierrabothwell | [email protected] Distribution of this document is illegal Inform her that some antianxiety medications are safe to take while breastfeeding is breastfeedin St g uv , ia s .c h o e m - s T t h o e p M p a e rk d etp t l a ac k e in to g Bu h y e an r d a S n el t l i y a o n ur x S i t e ud ty y M m at e er d ia i l cations, 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? A. describe the transmission of drugs to the infant through breast milk B. encourage her to use stress relieving alternatives, such as deep breathing exercises C. D. Explain that anxiety is a normal response for the mother of a 3-week-old. E. Rationale: there are several antianxiety medications that are not contraindicated for breastfeeding mothers. 41.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? A. Start an intravenous (IV) infusion of normal saline B. obtain a serum potassium level C. administer the client's usual dose of insulin D. assess pupillary response to light E. 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. 42.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? A. increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure B. the antagonistic interaction among the various blood pressure medications has reduced their effectiveness D. the synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension 43.Which client is at the greatest risk for developing delirium? pain. B. an older client who attempted 1 month ago C. a young adult who takes antipsychotic medications twice a day D. a middle-aged woman who uses a tank for supplemental oxygen 44.Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? A. Reduce risks factors for infection B. Administer high flow oxygen during sleep C. Limit fluid intake to reduce secretions D. Use diaphragmatic breathing to achieve better exhalation 45. Which location should the nurse choose as the best for beginning a screening program for C. The additive effect of multiple medications has caused the blood pressure to drop too low A. An adult client who cannot sleep due to constant Stuvia.com - The Marketplace to Buy and Sell your Study Material Downloaded by: sierrabothwell | [email protected] Distribution of this document is illegal Serum calcium hypothyroidism? A. A business and professional women's group. B. An African-American senior citizens center C. A daycare center in a Hispanic neighborhood D. An after-school center for Native-American teens 46. 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? A. Measure vital signs B. Auscultate breath sounds C. Palpate the abdomen D. Observe the skin for bruising 47.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? A. capillary glucose B. urine specific gravity C. D. white blood cell count 48.What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? A. working together can decrease the risk for back injury B. C. Using two or three people increases client safety. D. turning instead of pulling reduces the likelihood of skin damage 49.A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client? A. 50.Which action should the school nurse take first when conducting a screening for scoliosis? A. Inspect for symmetrical shoulder height. 51.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? 52.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? A. 53.A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform? A. 54. The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication’s effectiveness, which laboratory values should the nurse monitor? Select The technique is intended to maintain straight spinal alignment. Baked apples topped with dried raisins Encourage a low-carbohydrate and high-protein diet Observe the antecubital fossa for inflammation. A. Assign a practical nurse (LPN) to determine if an apical radial deficit is present Stuvia.com - The Marketplace to Buy and Sell your Study Material Downloaded by: sierrabothwell | [email protected] Distribution of this document is illegal all that apply 55.AA client is admitted to isolation with the diagnosis of active tuberculosis.Which infection control measures should the nurse implement? A. Negative pressure environment B. contact precautions C. droplet precautions D. protective environment 56.A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child? 57.AA young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? A. Altered consciousness within the first 24 hours after injury. 58.AA female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs A. Rented movies and borrowed books to use while passing time at home 59.Which instruction should the nurse provide a pregnant client who is complaining of heartburn? A. Eat small meal throughout the day to avoid a full stomach. 60. A client is admitted to the intensive care