HESI VI EXIT EXAM
QUESTIONS AND CORRECT ANSWERS
2. A client who is admitted to the care unit with syndrome of inappropriate antidiuretic
hormone (SIADH) has developed osmotic demyelination. Which intervention should t
...
HESI VI EXIT EXAM
QUESTIONS AND CORRECT ANSWERS
2. A client who is admitted to the care unit with syndrome of inappropriate antidiuretic
hormone (SIADH) has developed osmotic demyelination. Which intervention should the
nurse implement first?
A) Patch one eye.
B) Evaluate swallow.
C) Reorient often.
D) Range of motion.
Answer: B )
Osmotic demyelination is also known as central pontine myelinolysis. This is a condition in which nerve damage is caused by the destruction of the myelin sheath covering nerve cells in the brainstem. The most common cause is a rapid, drastic change in sodium levels when a client is being treated for hyponatremia which is a common occurrence in SIADH.
3. The nurse is preparing a client who had a below-the-knee (BKA) amputation for
discharge to home. Which recommendations should the nurse provide this client?
(Select all that apply)
A) Wash the stump with soap and water.
B) Avoid range of motion exercise.
C) Apply alcohol to the stump after bathing.
D) Inspect skin for redness.
E) Use a residual limb shrinker.
Answer: A ) and D ) and E )
Answers are: A,D&E
Range of motion is needed to prevent comications and patient should avoid using alcohol on the stamp.
4. After 2 days treatment for dehydration, a child continues to vomit and have diarrhea.
Normal saline is infusing and the child’s urine output is 50ml/hour. During morning
assessment, the nurse determines that the child is lethargic and difficult to arouse.
Which should the nurse implemented?
A) Increase the IV fluid flow rate.
B) Review 24 hour intake and output.
C) Obtain arterial blood gases.
D) Perform a finger stick glucose test.
Answer: B )
The nurse should review the intake and output of the patient since it may be in
the presence of hypertonic dehydration, where the sodium concentration is high, so increasing the flow of intravenous fluid can further compromise the patient.
6. A male client with an antisocial personality disorder is admitted to an in patient mental
health unit for multiple substance dependency. When providing a history, the client
justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this
client’s history is most likely to include which finding?
A) Multiple convictions for misdemeanors and Class B felonies
B) Delusions of grandiosity and persecution.
C) Suicidal ideations and multiple attempts.
D) Photos and panic attacks when confronted by authority figures.
Answer: A )
illicit drugs are illegal drugs
7. An older client is admitted for repair of a broken hip. To reduce the risk for infection
postoperative period., which nursing care intervention should the nurse include the
client’s plan of care? (Select all that apply)
A) Administer low molecular weight heparin as prescribed.
B) Teach client to use incentive spirometer every 2 hours while awake.
C) Remove urinary catheter as soon as possible and encourage voiding.
D) Maintain sequential compression devices while in bed.
E) Assess pain level and medicate PRN as prescribed.
Answer: A ) and B ) and C )
A)Administer low weight molecular heparin as prescribed
B) Teach client to use incentive spirometer every 2 hours while awake
C) Remove urinary catheter as soon as possible and encourage voiding
The heparin is to prevent the occurrence of deep vein thrombosis which is likely to occur due to the surgery.
9. A client with arthritis has been receiving treatment with naproxen and now reports
ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should
the nurse monitor?
A) Serum Calcium.
B) Erythrocyte sedimentation rate.
C) Osmolality.
D) Hemoglobin.
Answer: D ) Hemoglobin
10. A client with bacterial meningitis is receiving phenytoin. Which assessment finding
indication to the nurse that the client is experiencing a therapeutic response to the
phenytoin?
A) Increased time of ambulation between periods of rest.
B) Decrease in intracranial pressure and cerebral edema.
C) Absence of seizure activity for the duration of treatment.
D) Normal electroencephalogram after drug administration.
Answer:
· C. Absence of seizure activity for the duration of treatment.
Phenytoin is an anticonvulsant medication. Since meningitis can cause seizures, phenytoin can be used in patients with meningitis, to stop or prevent seizures. The therapeutic response to the phenytoin is indicated by the absence of seizure activity for the duration of treatment.
11. A client peptic ulcer disease receives a prescription for intermittent suction via a
SalemSump nasogastric tube (NGT). After inserting the NGT and obtaining coffeeground gastric contents, the nurse clamps the NGT because the client must leave the
unit for diagnostic studies. Upon return to the unit, the client complains of nausea. What
action should the nurse implement first?
A) Administering a prescribed antiemetic agent.
B) Provide oral suction using a Yankauer tip.
C) Connect the NGT to low intermittent suction.
D) Irrigate the NGT with sterile normal saline.
· C. Connect the NGT to low intermittent suction.
In bleeding peptic ulcer disease, the blood can accumulate in the stomach and irritate the lining of the stomach. This irritation causes nausea. The blood should therefore be suctioned to prevent or relieve the nausea. The suction should be done under low intermittent pressure to avoid worsening the bleeding. The best action is thus: Connect the NGT to low intermittent suction.
12. The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000
ml to be influenced over 4 hours. The IV administration set delivers 10 gtt/ml. How many
gtt/minute should the nurse regulate the infusion? ( round the nearest whole number.)
ANSWER; 41.667gtt/min
Flow rate(gtt/min) = volume(ml)/ time(min) × drop factor(gtt/mL).
Flow rate=1000ml/240min×10gtt/ml.
13. A family member reports that the client who is bedridden has not been turned or
repositioned all night and is sleeping on a special air mattress with no sheets. What
information should the nurse provide to the family member?
A) Clarify that an aerated support surface does not use sheets that often cause skin
breakdown.
B) Described the night staff’s plan of care to ensure the client’s sleep is not disturbed.
C) Explained that turning is only necessary to reposition the client during waking hours.
D) Suggest that a family member turn the client during the night when someone is there.
A) Clarify that an aerated support surface does not use sheets that often cause skin breakdown.
15. A client with bleeding esophageal varies receives vasopressin IV. What should the
nurse monitor for during the IV infusion of this medication?
A) Vasodilation of the extremities.
B) Chest pain and dysrhythmia.
C) Hypotension and tachycardia.
D) Decreasing GI cramping and nausea.
Answer: B )
16. The healthcare provider prescribes potassium chloride 25 mEq in 500ml D5W to
infuse over 6 hours. The available 20ml vial of potassium chloride is labeled, “How
many ml of potassium chloride should the nurse add to the IV fluid? (Round to the
nearest tenth.)
17. A male client reports to the on-call clinic nurse that he took tadalif 10 mg PO two
hours age and his skin now feels flushed. He reports a history of stable angina, but
denies experiencing any current or recent chest pain. What action should the nurse take?
A) Tell the client to have someone bring him to an emergency department immediately.
B) Advise the client to place one nitroglycerin tablet under his tongue as a precaution.
C) ?Reassure the client that skin flushing is a common side effect of the
medication.
D) Instruct the client to increase his intake of oral until the skin flushing is relieved.
18.The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider?
A) The client complains of abdominal fullness and cramping during installation.
B) The client complains of a slight shortness of breath during installation.
C) The amount of the returning dialysis fluid is greater than the amount instilled.
D) ?The appearance of the returning dialysate fluid is cloudy.
19. The healthcare provider prescribed furosemide for a 4-year old child who has
a ventricular septal defect. Which outcome indicates to the nurse that this
pharmacological intervention was effective?
A) Urine specific gravity change from 1.021 to 1.031 B) ?Daily weight decrease of 2 pounds (0.9 kg)
C) Urinary output decrease of 5 ml/hour.
D) Blood urea nitrogen (BUN) increase from 8 to 12 mg/dl (2.9 to 4.3)
20. The nurse is preparing to administer an oral antibiotic to a client with unilateral
weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority
nursing assessment that should be done before administering this medication?
A) Ask the client about soft food preferences. B) Determine which side of the body is weak. C) Obtain and record the client’s vital signs.
D) Auscultate the client’s breath sounds.
21. The nurse is demonstrating correct transfer procedures to the unlicensed
assistance personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse
how to safely move a physically disabled client from the wheelchair to a bed. What
action the nurse recommend?
A) Apply a gait belt around the client’s waist once a standing position has been assumed.
B) Pull the client into position by reaching from the opposite side of the bed.
C) Hold the client at arm’s length while transferring to better distribute the body weight. D) Place the client’s locked wheelchair on the client’s strong side next the bed.
22. A young adult woman visits the clinic and learns that she is positive for BRCA1
gene mutation and asks the nurse what to expect next. How should the nurse respond?
A) Provide information about survival rates women who have this genetic mutation. B) Gather additional information about the client’s family history for all types of cancer.
C) Offer assurance that there are a variety of effective treatments for breast cancer.
D) Explain that counseling will be provided to give her information about her cancer
risk.
23. The nurse is supervising an unlicensed assistive personnel (UAP) who will be
providing personal care for a client with watery diarrhea caused by Clostridium
difficile. Which action by the nurse takes priority?
A)? Remind the UAP to keep the client’s water pitcher filled. B) Review use of personal protective equipment with the UAP. C) Provide barrier cream for application to the perineal area. D) Instruct the UAP to record the number of bowel movements.
24. The nurse enters the room of a client who is awaiting surgery for appendicitis. The
unlicensed assistive personnel (UAP) has helped the client to a position of comfort
with the right leg flexed and has applied a heating pad to the client’s abdomen to
relieve the client’s pain. Which action should the nurse implement first?
A) Determine if the consent form has been signed by the client. B) Remove the heating pad from the client’s abdominal area.
C) Confirm that the UAP has assisted the client to a position of comfort. D) Evaluate the effectiveness of the heating pad in relieving pain.
Answer:
The correct answer is B. Remove the heating pad from the client's abdominal area.
Application of heat to the abdomen of the patient with appendicitis is dangerous as the patient can be having peritonitis which will rupture if heat is applied. Rupturing or perforation will expose the patient to infections.
25. The nurse completed a dressing change for a client with partial thickness burns
to both legs. After completing the dressing change, What intervention should the
nurse implement?
A) Administer a PRN dose of pain medication. B) Raise this head of bed to a 90 angle.
C) Perform passive range of motion.
D) Position ankles in a dorsiflexed position.
Answer:
Administer a PNR dose to the client for pain medication.
This will help alleviate pain and suffering of the patient and ensure that patient recovers as expected.
26. A client is admitted to a medical unit with a diagnosis of gastritis and chronic
heavy alcohol abuse. What should the nurse administer to prevent the development of
Wernicke’s syndrome?
A) Atenolol. B) Famotidine. C) Thiamine. D) Lorazepam.
27. Following laser trabeculoplasty surgery for open-angle glaucoma, the client
reports acute pain deep within the eye. What action should the nurse take?
A) Apply bilateral eye shields to reduce photosensitivity. B) Begin postoperative prophylactic antibiotics.
C) Administer an antiemetic to prevent vomiting. D) Report the complain of eye pain to the surgeon.
Answer:
A. Apply bilateral eye shields to reduce photosensitivity.
After an open-angle glaucoma surgery, patients should have eye shields so as to reduce photosensitivity which results into acute pain. The shield should be put over the eye for the first 24 hours after surgery. The nurse should therefore, apply bilateral eye shields to reduce photosensitivity.
28. A male client with cirrhosis has jaundice and pruritis. He tells the nurse that he
was been soaking in hot baths at night with no relief of his discomfort. What action
should the nurse take?
A) Explain that the symptoms are caused by liver damage and cannot be relieved. B) ?Encourage the client to use cooler water and apply calamine lotion after soaking. C) Obtain a PRN prescription for an analgesic that the client can use for symptom relief. D) Suggest that the client take brief showers and apply oil-based lotion after showering.
30. A 17-year-old adolescent is brought to the Emergency Department by both
parents because the adolescent has been coughing and running a fever with flu-like
symptoms for the past 24 hours. Which intervention should the nurse implement first?
A) Assess the client’s temperature.
B) Place a mask on the client’s face. C) Determine the client’s blood pressure. D) Obtain a chest x-ray per protocol.
31. The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a
urinary tract infection. Which client data requires the most immediate intervention by the nurse?
A) White blood cell count of 12,000 mm^3 (12 x 10^9/L SI) B) Serum sodium of 145 men/L (145 mm/L SI)
C) Urine culture positive for MRSA.
D) Serum creatinine of 4.5mg/dl (398 mom/L SI)
32. A young adult female presents at the emergency center with acute lower
abdominal pain. Which assessment finding is most important for the nurse to report to
the healthcare provider?
A) Reports white, curly vaginal discharge.
B) Last menstrual period 7 weeks ago. C) History of irritable bowel syndrome (IBS) D) Pain scale rating of a “9” on a 0-10 scale.
33. A client is admitted to the intensive care unit with diabetes insidious due to a
pituitary gland tumor. Which potential complication should the nurse monitor
closely? A) Ketonuria.
B) Peripheral edema. C) Hypokalemia.
D) Elevated blood pressure.
34. A male client is returned to the surgical unit following a left nephrectomy and is
medicated with morphine sulfate 4 mg IV. His dressing has a small amount of bloody
drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which
intervention is most important for the nurse to include in this client’s plan of care?
A) Assess for back muscle aches. B) Obtain body weight daily.
C) Monitor urinary output hourly. D) Record drainage from drain.
36. When administering ceftriaxone sodium intravenously to a client before surgery,
which assessment finding requires the most immediate intervention b the nurse.
A) Headache.
B) Pruritis. C) Stridor. D) Nausea.
Answer:
B) Pruritis.
Pruritis after administration of IV cefriaxone indicate allergic or anaphylactic reaction,so immediate intervention is required
37. The nurse is complaining an admission assessment for a male client with
paranoid schizophrenia. The client tells the nurse that the staff dislikes him. What
action should the nurse take?
A) Assess the client’s speech pattern for a flight of class.
B) Observe the client for obsessive activities such as repeated hand washing. C) Determine if the client has formulated any plans regarding the staff.
D) Ask the client if he has a plan to harm himself.
39. The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her
baby using a Medela Haberman feeder, which has a valve to control the release of
milk and a slit nipple opening. The nurse discusses placing the nipple’s elongated tip
in the back of the oral cavity. What instruction should the nurse provide the mother
about feedings?
A) Alternate milk with water during the feedings.
B) Squeeze the nipple base to introduce milk into the mouth.
C) Position the baby in the left lateral position after feeding.
D) Hold the newborn in an upright position
