HESI Exit Exam 4 - Question and Answers with Rationale

HESI Exit Exam 4 - Question and Answers with Rationale HESI Exit Exam 1. A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which response to the medication? 2. A ro ...

HESI Exit Exam 4 - Question and Answers with Rationale HESI Exit Exam 1. A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which response to the medication? 2. A routine urinalysis is prescribed for a client. What should the nurse do if the specimen cannot be sent immediately to the laboratory? 3. A nurse is notified that the latest potassium level for a client in acute renal failure is 6.2 mEq. What action should the nurse take? 4. A client with a diagnosis of uncontrolled diabetes began receiving Lasix (Furosemide) two days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take? 5. Which is the most serious complication for which the nurse must monitor a client with kidney failure? 6. An obese client who is mildly hypertensive is hospitalized with a diagnosis of ureteral colic and hematuria. What is the immediate focus of nursing care for this client? 7. A client in a nursing home is diagnosed with urethritis. What should the nurse plan to do before initiating antibiotic therapy prescribed by the health care provider? 8. A client with Type I Diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action? 9. A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. The nurse's teaching plan should include instructions to: 10. A nurse is counseling a woman who had recurrent urinary tract infections. What factor should the nurse explain is the reason why women are at a greater risk than men for contracting a urinary tract infection? 11. A client has undergone surgery with general anesthesia. Within how many hours after surgery should the nurse notify the health care provider if the client does not void? 12. A client with a urinary retention catheter reports discomfort in the bladder and urethra. What should the nurse do first? 13. A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when teaching the client about health practices that may help decrease future urinary tract infections? 14. A client is admitted to a medical unit with the diagnosis of acute kidney failure. The nurse reviews the client's laboratory data, performs a physical assessment, and obtains the client's vital signs. What should the nurse conclude the client is most likely experiencing? 15. A nurse is caring for a client with the diagnosis of pemphigus vulgaris. Which expected response does the nurse need to address in the client's plan of care? 16. A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have? 17. A nurse teaches a client who is scheduled for a kidney transplant about the need for immunosuppressive medications. The nurse determines that the client understands the teaching when the client states, "I must take these medications: 18. A nurse is assessing the urine of a client with a urinary tract infection. What appearance should the nurse expect this client's urine to have? 19. The nurse provides discharge instructions to a male client that had a ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). The teaching should include that indicators of a UTI are: 20. A client with a detached retina is scheduled for surgery to reattach the retina. What should the nurse address in the preoperative teaching plan about the procedure used with this surgery? 21. The nurse recalls that what scientific principle is basic to caring for a client with an indwelling urinary catheter? 22. A client has an order for a sublingual nitroglycerin tablet. The nurse should teach the client to use what technique when self-administering this medication? 23. A client is scheduled to have an indwelling urinary catheter inserted before abdominal surgery. The nurse should insert the catheter in what location in the illustration? 24. The nurse is caring for a client with ureteral colic. To prevent the development of renal calculi in the future, the client's plan of care should include: 25. The health care provider prescribes furosemide (Lasix) for a client with hypervolemia. The nurse recalls that furosemide exerts its effects in what part of the renal system? 26. Twenty-four hours after a penile implant the client's scrotum is edematous and painful. The nurse should: 27. A nurse is teaching a community group about the basics of nutrition. A participant questions why fluoride is added to drinking water. The nurse should respond that it is a necessary element added to drinking water to promote: 28. Trimethoprim-sulfamethoxazole (Septra) is prescribed for a client with cystitis. When teaching about the medication, the nurse instructs the client to: 29. A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? 30. A nurse is teaching the importance of annual physical examinations to an adult health and wellness class. The nurse reinforces that it is important for men who are middle-aged and older to have what laboratory test annually? 31. A nurse assesses a newly admitted client with renal colic to determine the signs and symptoms that are present. The nurse assesses the client for which primary subjective symptom? 32. A client is taught how to change the dressing and how to care for a recently inserted nephrostomy tube. On the day of discharge the client states, "I hope I can handle all this at home; it's a lot to remember." The best response by the nurse is: 33. A client with chronic kidney disease has been on hemodialysis for two years. The client relates to a nurse in the dialysis unit in an angry, critical manner and frequently does not follow the prescribed diet or take prescribed medications. What does the nurse identify as the most likely underlying cause of this behavior? 34. A nurse administers sodium polystyrene sulfonate (Kayexalate) to a client with chronic renal failure. Which finding provides evidence that the intervention is effective? 35. A client who is 5 feet, 8 inches tall and weighs 220 pounds is admitted to the hospital with ureteral colic, blood in the urine, and a blood pressure of 150/90. The immediate objective of nursing care for this client is to decrease: 36. A nurse is caring for a client with an indwelling urinary catheter. What is the most important action for the nurse to implement when irrigating the bladder? 37. A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What should the nurse expect to identify when assessing this client? 38. A client is admitted with extensive bone and soft-tissue injuries to the leg. Sterile dressings are applied. Two days later, when removing the dressings, the nurse finds that one of the dressings has adhered to tissue in several places. To loosen the dressings, the nurse should: 39. A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding? 40. A client develops a maculopapular rash on the upper extremities and audible wheezing during the administration of intravenous vancomycin (Vancocin). To ensure the client's safety, which action would the nurse carry out first? 41. A client is admitted to the hospital with a ureteral calculus. The nurse expects what urinary clinical findings? 42. A client with urge incontinence is receiving oxybutynin (Ditropan XL) 30 mg orally. Each tablet contains 5 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets 43. An obese client who is mildly hypertensive is hospitalized with a diagnosis of ureteral colic and hematuria. What is the immediate focus of nursing care for this client? 44. Trimethoprim-sulfamethoxazole (Septra) is prescribed for a client with cystitis. When teaching about the medication, the nurse instructs the client to: 45. A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of: 46. A nurse teaches a client who is scheduled for a kidney transplant about the need for immunosuppressive medications. The nurse determines that the client understands the teaching when the client states, "I must take these medications: 47. While watching television in the dayroom a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallway. What is the most therapeutic intervention by the nurse? 48. An adolescent who gave birth one day ago confides to the nurse that she hopes that her baby will be good and sleep through the night. What should the nurse include in the plan of care to facilitate a realistic expectation of a nighttime newborn schedule? 49. After 8 postpartum hours the nurse determines that a client's fundus is 3 cm above the umbilicus and displaced to the right. Which statement is most significant in confirming the reason for the location of the uterus? 50. After working for a week with an adolescent with anorexia nervosa, the adolescent becomes hostile and says to the nurse, "You're just like my mother. I hate you." What concept does the client's statement reflect? 51. A woman comes into the clinic and states that she is thinking about becoming pregnant. What can the woman do to improve the health of her baby before she becomes pregnant? 52. On a return visit to the fertility clinic a couple requests fertility drugs because, despite having a 28-day menstrual cycle and temperature readings that demonstrate an ovulatory pattern, the woman has been unable to conceive. What should the nurse explain to the couple? 53. The parents of an overweight adolescent girl tell the nurse that they are concerned that their daughter feels inferior to her sister, who is an attractive, successful college senior. They ask the nurse what they can do about this problem. The nurse should: 54. When talking with the nurse, a client with a mood disorder says, "I feel rotten. I feel useless. I can't think straight. I feel overwhelmed by everything. I don't know if I can go on." What should the nurse document when describing this encounter? 55. A 20-year-old carpenter falls from a roof and sustains fractures of the right femur and left tibia. The client reveals a history of substance abuse. What is the primary consideration for the nurse who is caring for this client? 56. Many people control anxiety with the use of ritualistic behavior. What must the nurse do when caring for these clients? 57. What characteristic of an environment should the nurse consider important for a confused older adult with socially aggressive behavior? 58. A 67-year-old man with type 2 diabetes sadly confides in the nurse that he has been unable to have an erection for several years. What is the best response by the nurse? 59. A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do? 60. The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the mostappropriate response by the nurse? 61. A nurse is providing information about Alcoholic Anonymous (AA) meetings to a client with a history of alcohol abuse. What will be required when the client attends AA meetings? 62. A nurse understands the stages of parental adjustment that follow the birth of an at-risk infant who is in the neonatal intensive care unit. To better plan nursing care, the nurse bases observations and assessments on the recognition that the: 63. A postpartum client is scheduled to have a tubal ligation. She has asked that her husband not be told about the procedure because she has told him that she is having exploratory surgery. The client's husband asks the nurse why his wife needs to have exploratory surgery. How should the nurse respond? 64. When a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, the client shouts, "Get out of here!" What is the most therapeutic response? 65. A client who has been attending a day treatment facility for 1 month with the diagnosis of major depression is to be discharged in a week. Because the nurse and the client are aware of this, what is the most appropriate comment by the nurse? 66. A client in a detoxification unit has an alcohol withdrawal seizure. Diazepam (Valium) 7.5 mg intramuscularly stat is prescribed. Valium is available 5 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place. __________ mL 67. A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child's birth 3 years ago. What is most directly related to the client's loss of interest in sex? 68. A nurse is caring for a client with an obsessive-compulsive personality disorder that involves rituals. What should the nurse conclude about the ritual? 69. A young sexually active client at the family planning clinic is advised to have a Papanicolaou (Pap) smear. She has never had a Pap smear before. What should the nurse include in the explanation of this procedure? 70. A 7-year-old boy is brought to the clinic by the mother, who tells the nurse that her child has been having trouble in school, has difficulty concentrating, and is falling behind in schoolwork since she and her husband separated 6 months ago. The mother reports that lately her child has not been eating dinner, and she often hears him crying when he is alone. What basis for these behaviors should the nurse consider? 71. A client elects to have her pregnancy terminated after finding out at 16 weeks' gestation that she is carrying a fetus with Down syndrome. What should the nurse conclude about an abortion at this stage of the pregnancy? 72. A nurse from the pediatric clinic who is strongly opposed to any chemical or mechanical method of birth control is asked to work in the family planning clinic. What is the most professional response that this nurse could give to the requesting supervisor? 73. On the afternoon of admission to a psychiatric unit, an adolescent boy with the diagnosis of schizophrenia exposes his genitals to a female nurse. What should the nurse's immediate therapeutic response be? 74. A nurse has been assigned to work with a depressed client on a one-on-one basis. The next morning the client refuses to get out of bed, saying, "I'm too sick to be helped, and I don't want to be bothered." What is the best response by the nurse? 75. A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped and my veins have turned to glass!" What should the nurse conclude that the client is experiencing? 76. An older client is transferred to a nursing home from a hospital with a diagnosis of dementia. One morning, after being in the nursing home for several days, the client is going to join a group of residents in recreational therapy. The nurse sees that the client has laid out several outfits on the bed but is still wearing nightclothes. What should the nurse do? 77. A female client with acute schizophrenia tells the nurse, "Everyone hates me." What is the best response by the nurse? 78. One statement by a breastfeeding mother that indicates that the nurse's teaching about stimulating the let-down reflex has been successful is "I will: 79. A 16-year-old high school student who has anorexia nervosa tells the clinic nurse that she thinks she is pregnant even though she has had intercourse only once, more than a year ago. What is the most appropriate inference for the nurse to make about the student? 80. A depressed client says, "I'm no good. I'm better off dead." What is the priority nursing intervention? 81. An 8-year-old child is found to have oppositional defiant disorder. What behavior noted by the nurse supports this diagnosis? 82. A nurse is counseling a pregnant client who is a vegetarian. What should the nurse plan to do to ensure optimal nutrition during the pregnancy?