HESI EXIT EXAM 1 – QUESTION AND ANSWERS 2021 updated Exam(Graded A)

HESI Exit Exam Question and Answers When the implementation of a plan of care does not produce the desired outcome effectively, the plan should be changed. Time is not relevant in the revision of a plan of care. Clien ...

HESI Exit Exam Question and Answers When the implementation of a plan of care does not produce the desired outcome effectively, the plan should be changed. Time is not relevant in the revision of a plan of care. Client response to care is the determining factor, not the validity of the health problem. Various methods may have the same outcome; their effectiveness is most important. A client with a dysrhythmia is admitted to telemetry for observation. In the morning, the client asks for a cup of coffee. What is the nurse’s best response? A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is: A client asks the nurse, “Should I tell my partner that I just found out I’m human immunodeficiency virus (HIV) positive?” What is the nurse’s most appropriate response? A client will be receiving monthly intramuscular doses of cyanocobalamin (Vitamin B12), 200 mcg. The medication is available at 100 mcg/mL. Which syringe contains the correct amount of medication for the ordered dose? The professional obligation of a nurse to assume responsibility for actions is referred to as: A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response? After changing a dressing that was used to cover a draining wound on a client with Vancomycin-Resistant Enterococcus (VRE), the nurse should take which step to ensure proper disposal of soiled dressing? The spouse of a client who had emergency coronary artery bypass surgery asks why there is a dressing on the client’s left leg. The nurse explains that: A nursing team leader identifies that a nurse is coming to work after drinking alcohol. What is the most appropriate way for the team leader to approach this ethical situation? A client diagnosed with tuberculosis is taking isoniazid (INH). To prevent food and drug interaction, the nurse should advise the client to avoid: A nurse is providing post-procedure care to a client who had a cardiac catheterization via a brachial artery. For the first hour after the procedure, what is the priority nursing intervention? A client with a dysrhythmia is admitted to telemetry for observation. In the morning, the client asks for a cup of coffee. What is the nurse’s best response? A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is: A client asks the nurse, “Should I tell my partner that I just found out I’m human immunodeficiency virus (HIV) positive?” What is the nurse’s most appropriate response? A nurse is reviewing a client’s plan of care. What is the determining factor in the revision of the plan? A client will be receiving monthly intramuscular doses of cyanocobalamin (Vitamin B12), 200 mcg. The medication is available as 100 mcg/mL. Which syringe contains the correct amount of medication for the ordered dose? A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion? One week after admission to the cardiac care unit a client displays an outburst of anger and tells the nurse to get out of the room. Which is the most appropriate nursing action? As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults’ most frequent causes of falls? 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: The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client’s pain: A nurse is teaching Unlicensed Assistive Personnel (UAP) about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through: A nurse identifies that a client who had a myocardial infarction is struggling with an alteration in self-concept. The nurse intervenes to promote client autonomy. The behavior that demonstrates an increase in client autonomy is when the client: A nurse on the medical-surgical unit tells other staff members, “That client can just wait for the lorazepam (Ativan); I get so annoyed when people drink too much.” What does this nurse’s comment reflect? A client who has hemoglobin of 6 gm/dL is refusing blood because of religious reasons. What is the most appropriate action by the nurse? A client with small-cell lung cancer is receiving chemotherapy. A complete blood count is prescribed before each round of chemotherapy. The component of the complete blood count that the nurse is concerned about most is: During history taking, a client reports experiencing black, tarry stools. The nurse recognizes that this may be an indication of: A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a total laryngectomy is scheduled. Which nursing action is most important in the immediate postoperative management of this client? A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, “I cannot discuss any client’s illness with you.” What legal issue supports the nurse’s response? A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? A nurse is a preceptor for an orientee (newly hired nurse). The orientee is providing postoperative care to a client who recently returned from a laryngoscopy. The orientee reminds the client not to eat or drink anything until instructed to do so. The preceptor informs the orientee that the instructions given to the client were: When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? A client is admitted to the emergency department with a stab wound of the chest. What is the priority when the nurse performs a focused assessment of the client’s response to this injury? A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco2 of 60. These blood gases require nursing attention because they indicate: The nurse is developing a plan of care for a client that had a chest tube removed. To promote respiratory exchange, the plan should include: Two nurses are planning to help a client with a one-sided weakness to move up in bed. What should the nurses do to conform to a basic principle of body mechanics? The nurse provides discharge teaching to a client with tuberculosis and reinforces that the treatment measure with the highest priority is: During an admission assessment, the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action? A nurse is caring for a client with a history of gastrointestinal (GI) irritability. What should the nurse advise the client to avoid limiting GI irritability? Which client assessment finding should the nurse document as subjective data? What factors are most important for the nurse to consider when delegating responsibilities? A nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos should the nurse include in the teaching plan? A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. The nurse is frustrated and tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse’s behavior be interpreted? A health care provider prescribes a sigmoidoscopy for one client and a barium enema for another client. What is a nursing responsibility common to preparing both of these clients for these procedures? A client who had abdominal surgery asks the nurse about when the client can return to work after discharge. The most appropriate response by the nurse is: A client has severe diarrhea, and the health care provider prescribes intravenous fluids, sodium bicarbonate, and an antidiarrheal medication. Which most frequently prescribed antidiarrheal drug does the nurse expect the health care provider to prescribe? A client has a paracentesis during which 1500 mL of fluid is removed. The nurse should monitor the client carefully for: An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every four hours. Which diet should the nurse expect the health care provider to prescribe to best meet this client’s immediate nutritional needs? Prednisone (Meticorten) is prescribed for a client with an exacerbation of colitis. Before administering the first dose, the nurse teaches the client that: The nurse observes that an older client seldom eats the meat on the meal trays. The nurse discusses this observation with the client, and the client states, “I only eat meat once a week because old people don’t need protein every day.” The nurse determines that the client needs to be taught about the: A nurse applies a heating pad to a client’s buttocks. Upon removal of the heating pad, the nurse discovers that the client has received burns due to incorrect settings when the use of the heating pad was initiated. Which principle would legally apply? A client is scheduled for a colonoscopy, and the health care provider prescribes a tap water enema. In which position should the nurse place the client during the enema? A client describes abdominal discomfort following the ingestion of milk. Which enzyme, as a result of a genetic deficiency, should the nurse consider being the cause of the client’s discomfort? A client with gastroesophageal reflux is to receive metoclopramide (Reglan) 15 mg orally before meals. The concentrated solution contains 10 mg/mL. How many solutions should the nurse administer? Record your answer using one decimal place. _______ mL The diet prescribed for a client with diverticulosis includes 30 grams of fiber a day. What breakfast items should the nurse encourage the client to select? A client has a large open abdominal wound. The health care provider’s prescription states to cleanse the wound with normal saline, pack the wound with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. What should the nurse do to maintain sterility when changing the dressing? A visitor says to the nurse, “Can I read my client’s progress record? I am the sponsor from an alcohol recovery program.” How should the nurse respond? A client with a rigid and painful abdomen is diagnosed with a perforated peptic ulcer. A nasogastric tube is inserted and surgery is scheduled. Before surgery, the nurse should place the client in what position? Prednisone (Meticorten), an adrenal steroid, is prescribed for a client with an exacerbation of colitis. When administering the first dose of the medication, the nurse should inform the client that the medication: