Hesi Exit Exam

HESI EXIT EXAM 1. a male client admitted the morning of his scheduled surgery tells the PN that he drank water last night. What intervention will the PN implement first? Determine the amount of water and exact time it was taken 2. A client receives ondansetron prior to chemotherapy treatment.How should the PN evaluate this medication? Monitor the client for nausea or vomiting following the treatment 3. The PN is caring for an older adult client who is confused and spends...factor contributes to an increased risk for impaired skin integrity for this client? Has increasing episodes of urinary incontinence 4. The pn determines that a client with cirrhosis is experiencing peripheral....take? Protect the clients feet from injury 5. A client is admitted to the postoperative surgical unit after a left lobectomy with two chest tubes......observes the water-sealed chambers, set and prescribed suction of 20cm water...what action should the PN implement? Maintain system integrity and to promote lung reexpansion 6. photo of chest and locating apical HR just below the left nipple 7. At the end of a 12-hour shift the PN observes the urine in a clients drainage..what action should the PN take next? note the most recent white blood count 8. Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his pain...what action should the PN implement first? implement complementary pain relief methods 9. A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in....with one or two word responses. the morning the PN observes that he...Which intervention is most important for the PN to implement? Measure appropriate vital signs 10.The PN is assisting a female client to obtain a voided specimen for uri...meatus. Which intervention is performed next? initiate the urine stream? 11.An 8-year old is placed in 90-90 traction for a fractured femur that resulted from...further action by the PN? weights are touching the foot of the bed 12.The PN is reviewing diet instructions with a female client who has hyper...she has increased her intakes of protein and calories. What action should the PN take? Encourage the client to continue the dietary changes she has made 13.The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis and is preparing for discharge from the hospital. What... -why the fluid measurements need to be recoded 14.-which food types are included when measuring fluid take 15.-what container to use for the most accurate measurement 16.... request return visit for examination after her period when hormones are lowest 17.A mother brings her 5-year old child to the clinic for school physical examinations. Which assessment... PN that intergenerational violence may be occurring in the home? -The 6-year old son hits his younger sister during the interview 18.-the 10-year old daughter has circular burns on her trunk and legs 19.-the 3-year old has multiple bruises on the chest and both legs 20.A client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 mL per hour is...1200 the PN notes that there are 750 ml of solution remaining.At what time should the nurse expect to discontinue the intravenous therapy? 1700 21.the PN is caring for a client who had a total laryngectomy, left radical neck dissection... client is receiving nasogastric tube feedings via an internal pump. today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding? gastric residual volumes 22.A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take? Ensure that all the areolar tissue of the nipple is in the infants mouth. 23.Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? deltoid 24.Before inserting medication into a clients vagina, what instructions should the pn... urinate until bladder is empty 25.An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which information is best for the PN to provide? A history of untreated gonnorhea can lead to PID 26.A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort? Wear a supportive bra at all times 27.A young adult male tells the PN he has declared to change his hours at work so that he can...his community. Which stage of Maslow's development is this young adult attempting to achieve? Self-actualiztion 28.A female client arrives to the clinic for an annal physical examination. when reviewing...the PN that she takes herbs for high blood pressure instead of the prescribed..important for the PN to reinforce with the client? Explain risks associated with using herbs instead of the prescribed antihypertensives. 29.A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client "this type..hospital" what intervention should the PN implement ? Act as the clients advocate when discussing the issue with the HCP 30.The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to include in the nursing care plan? watch the client for abnormal bleeding 31.... "it is better to obtain children acetaminophen to prevent possible side effects from the aspirin " 32.A client is transferred to the surgical unit from the intensive care unit after evacuation of bilateral..primary observation should the PN monitor? neuro-vital signs related to bleeding and intracranial pressure 33.The PN is working the day shift in a long term facility and is preparing..delegate to the UAP to perform during the change of.. total the clients PO intake, fill the water pitchers, empty urinals and catheter bags. 34.While taking the vital signs of a older male client who takes psychotropic medication...uncontrollable hand movements ad is excessively blinking his eyes, which information.... screening for tardive dyskinesia 35.A female client tells the PN that her hemorrhoids are inflamed and hurt..the PN to implement to complete a focused assessment? position client in left lateral position to inspect perianal area for fissures or sacs 36.the PN is implementing the plan of care for a client who admits having...indicates the highest risk for the client acting on these suicidal thoughts? Begins to show signs of improvement 37.The PN observes that a male clients urinary catheter drainage tubing is...the attached to the bed frame. What action should the PN implement? observe the appearance of the urine in the drainage tubing 38.A 150 pound adult client with Partial-thicknees burns over 40% of the body..hospital burn unit. Which observation is most important for the Pn to report... urinary output of 20 mL/hr 39.The PN notes that an elderly client has developed nonproductive...the previous day. Vital signs are temperature 99.8 F; pulse 94; respirations 22; and BP...important for the PN to implement? report the findings to the charge nurse 40.The PN is making shift assignment at an extended care rehabilitation...assign to the UAP. -Toileting assistance for a client receiving therapy after a total hip replacement 41.-daily skin care for a client with a descending double barrel colostomy 42.-morning care for a client with a staph wound infection 43.A client is complaining of a tightening sensation in the fingers, nose tip and ear lobes...24...PN should be prepared to implement what measure first? Obtain prescribed calcium gluconate for tetany 44.A clients chief complaint is being able to swallow only small bites of solid food...PN should assess for what additional information? History of alcohol and tobacco use 45.An adult female client with type 1 diabetes mellitus is receiving 35 units of NPH insulin...PN document as evidence that the amount of insulin is inadequate... Consecutive evening serum glucose readings of >260 mg/dl 46.The PN is assigned the care of four clients on a medical-surgical...prioritze client assessments -A client who is admitted with a suspected ruptured appendix 47.-A client who is post-lumbar puncture is reporting a severe headache 48.-An older male adult with Alzheimers who wanders out of his room 49.-A postoperative client who needs reinforcement of discharge instruction 50.Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream 51.An adolescent male with severe acne recently started treatment with isotretinoin, a form of Vitamin A. During a follow up clinic appointment, which assessment is most important for the PN to complete? Ask about occurrence and frequency of nosebleeds 52.The PN is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. what is most important to reinforce in this clients plan of care? interventions to decrease emotional stress 53.An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the the PN, who is taking the client the clients vital signs. What action should the PN implement ? reinforce the need for extra rest periods and plenty of sleep 54.The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond? Affirm the importance of rest to promote liver healing 55.when the PN plans daily care for a group pf clients, which client should the PN see first due to the risk of complication?` An older client with a stroke who is febrile and confused 56.which foot care instructions is most important for the PN to reinforce that minimizes a Long term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)? Report any food injury or sore that does not readily heal 57.during a clinic visit for a sore throat a clients basal metabolic panel reveals a serum potassium of 3.0bmL q/L. Which action should the PN recommend to the client based on this finding? increase intake of dried peaches and apricots 58.A client with a fractured left hip fracture is in Bucks's traction. The PN should expect the client to exhibit which outcome? The left foot is warm to touch with a palpable dorsals pedis pulse 59.When entering the room of an older female resident of a long term care facility, the PN finds one of the male residents in bed with her. What action should the PN take? Close the door and report the finding to the charge nurse 60.Prior to giving digoxin, the PN assesses that a 2-month old infants heart rate is 120 beats/min. Based on this finding what action should the PN take? give the medication and document the heart rate 61.A resident of a long-term care facility who has a drainage stage 2 pressure ulcer receives a prescription for sterile, warm, moist compress q12 hours for 20 minutes to the site. What precautions should the PN take when performing this procedure? select all that apply -remove soiled dressings with procedure gloved and don sterile gloves for moist dressing application 62.-place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the dressed site 63.-pour warmed sterile solution to an open sterile dressing tray that contained sterile gauze pads 64.A male client who is diagnosed with schizophrenia is taking an antipsychotic medication and calls the psychiatric clinic. The client tell the PN that he is achy and stiff, has a temperature of 103.4 F and is sweating. How should the PN respond to this client? direct the client to obtain immediate transportation to the emergency center 65.A client is diagnosed with with hyperthyroidism. Which symptoms should the PN expect this client to exhibit? muscle cramping and dry flushed skin 66.The PN administers an antibiotic to a client with a respiratory tract infection...evaluate the medications effectivesnn, which laboratory values should the PN monitor? b,d ABD 67.To obtain an estimate of a clients systolic blood pressure, what action should the PN take first? palpate the clients brachial pulse 68.A client reports feeling numbness and tingling in extremities. What action should the PN implement? review the clients serum electrolyte levels 69.Immediately after birth, which nursing intervention has the highest priority for the newborn infant? preventing heat loss and neonatal cold stress 70.A 0800 a clients apical pulse rate is 98 beats/minute> Four hours later the apical pulse rate is 54 beats/minute. What action should the PN take next? determine the level of consciousness 71.which client information is most important for the PN to consider when providing instructions to the UAP about providing morning care to a postoperative client? urinary output of 50 mL/hour 72.After report, the PN receives the laboratory values for four clients. Which client requires the PNs immediate intervention? a client who is trembling and has a glucose level of 50 73.Based on the nursing diagnosis of "risk for infection" which intervention should the PN implement when providing care for an elderly client with urinary incontinenece maintain standard precautions 74.During recovery after the delivery of a normal infant a client is receiving...ringers 1000 mL with oxytocin 20 units. The PN should evaluate the client for which therapeutic response? stimulation of uterine contractions 75.A 5-year old child is admitted with full thickness burns over 30% of the total body surface areas (TBSA). After fluid replacement therapy is initiated, which finding should the PN use to evaluate the effectiveness of the therapy? urine output 76.The PN enters the room of a client who is disoriented and has a wrist restraint secured as seen in the picture what action should the PN take? photo is of hospital bed and restraint Is on the bed frame in a bow tie use a full knot to secure the restraint line 77.A new mother asks the pn about an area of swelling on her baby head that lies across the suture line near the posterior fontanel. How should the PN respond? caput succedaneum will be absorbed and causes no problem 78.The PN obtains a finger stick glucose for a client with type 1 diabetes mellitus who is conscious and demonstrating hand tremors and shaking. The PN reports the clients result of 55 mg/dL to the nurse. What action should the PN implement next? provide the client with a glass of milk and crackers 79.A client who is primigravida at term comes to the prenatal clinic and tells the PN that she is having contractions every 5 minutes. The PN monitors the client for 1 hour using a external fetal monitor and determines that the clients contractions are 7 to 15 minutes apart lasting 20-30 seconds with mild intensity by palpation. What action should the PN take? send the client home and instruct her to call the clinic when her contractions are 5 minutes apart for one hour 80.the PN plans to evaluate an adults response to a prescription for colchicine. Last week the client was seen in the clinic for pain in the great left toe, which was the result of an acute attack of gout. which data should the PN obtain to evaluate the therapeutic effectiveness of this medication? pain scale level during walking 81.The PN is caring for a client who was recently diagnosed with hepatitis B virus (HBV). The PN observes that the clients urine is the color of dark tea. What action should the PN take? encourage increased oral fluid intake 82.A client develops generalized edema associated with chronic kidney disease (CKD). The PN understands the formation of the edema is the result of which physiological process? plasma protein losses resulting in decreased oncotic pressure within the vessels 83.The PN and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement? demonstrate to the UAP how to approach the client from the clients left side 84.when assessing an adult male who present at the community health clinic with a history of hypertension the nurse notes that he has 2+ pitting edema in both ankles. he also has a history of gastroesophogeal reflux disease and depression. which interventions is most important for the PN to implement? review the clients use of over the counter (OTC) medications 85.A client with Alzheimers disease (AD) is receiving trazadone (Desyrel) a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the clients mood and sleep patterns are improved but there is no change in cognitive ability. How should the nurse respond to this information? confirm that the desired effect of the medication has been achieved? 86.A client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the PN implement in response to the clients refusal ? emphasize the importance of active foot flexion 87.A client recovering from a stroke is learning how to use a cane. How should it be placed? on the stronger side of the body 88.A client with schizophrenia is withdrawn isolates himself in the day room and answers questions with one or two word responses which intervention is most important ? measure appropriate vital signs 89.While performing the apical pulse of an adult male client the PN notes that the point of maximal impulse is located at the 4th intercostals space medial to the midclavicular line what is the assessment for? expected finding 90.A client with type 2 diabetes becomes unresponsive and says I'm not feeling right which action should the PN take? give 4 ounces of apple juice 91.A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug? provide oral care 92.The PN is caring for a client in bucks tract what is the priority goal for the client in traction? maintain straight body alignment 93.Client with Hungtingtons disease starts jerking around while the family is there what should the PN do? offer emotional support to the family 94.Client voiding small amounts every 24 hoursthe catherterized volume determines the need to reinsert the indwelling catheter 95.A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client? measure all emeisies accurately 96.Single mother of a child with head injury comes crying to the clinic what should the PN tell her? this must seem overwhelming to you right now 97.on admission to the medical unit a client who is homeless and has a history of HIV with persistent cough? erythema and indurations of 5mm at site 98.When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given In the computer. What action should the PN take? contact the medication nurse to clarify the findings 99.A client is admitted for observation after experiencing a TIA high risk for injury 100. Which picture of nailbeds indicate hypoxia? choose the one that has a bump right below the nail bed 101. During morning report the PN learns that an assigned client has phlebitis from a intravenous access device. What will the PN observe in this client? redness, warmth, and edema of the site 102. The PN is caring for a client with atrial fibrillation. What would be an expected finding when assessing this client? heart rate 88 and irregular 103. A clients blood pressure is unusually elevated. Which factors would contribute to this clients blood pressure elevation? stress 104. exercise 105. heart rate 106. body temp 107. During morning report the PN learns that an assigned client has phlebitis from an intravenous access device. What manifestations will the PN assess in this client? palpable cord along the vein 108. How should the PN assist the client to provide sputum sample? coach the client to take deep breaths and cough deeply to mobilize secretions 109. A client with a fever is diaphoretic and the linens are saturated. After assessing the clients vital signs, which action would the PN take? change the bed linens 110. The PN provides a prescribed analgesic perianal spray to a postpartum client. For which problem will this nursing action address? vaginal lacerations 111. The charge nurse is making assignments for client care. Which client would be assigned to the PN for the assessment? client with confusion and sundowner syndrome 112. A client with a chest tube attached to a water sealed drainage system has had 400 mL of drainage over the last 8 hours. After morning care the client was repositioned and the chest tube drainage has been 0 ml for the last 2 hours. What action would the PN take at this time? increase the suction on the drainage system 113. The PN is caring for a client recovering from a transurethral resection of the bladder for prostate hypertrophy. The client has an indwelling urinary catheter and is receiving continuous bladder irigation of sterile normal saline at 100 mL per hour. the health care provider has prescribed to reduce the irrigation to 50 ml/hr if the clients output measurement is equal to 550 mL for 4 hours at which point would the PN reduce the clients bladder irrigation 1000 output measurement 550 mL 114. While inserting an indwelling urinary catheter into a female client the catheter slips into the clients vagina. What would the PN do? keep the catheter in the vagina and insert a new catheter through the urethral meatus 115. Six hours after removing a clients indwelling urinary catheter the client has not voided ad is expressing discomfort from a distended bladder. What action would the PN take? obtain an order for intermittent urinary catheterization 116. During a health history the PN learns that an older client had the chickenpox virus as a child. Which immunization would be indicated for the client at this time? vaccination for shingles 117. The PN is reviewing the state nurse practice act. What information will be included within the document? legal requirements for PN 118. The PN observes a family member provide passive ROM to a client paralyzed upper extremity, The family member is supporting the client elbow by holding above and below the joint through ROM. Which action would the ON take after making this observation? encourage the family member to continue because the procedure is being done correctly 119. a client is diagnosed with respiratory acidosis. What blood pH value will the PN assess when reviewing the clients arterial blood gas results? 7.29 120. A 16 year old client is preceded to receive 1.0 mL of an intramuscular injection. Which sites would the PN consider to administer this medication? deltoid 121. 122. ventrogluteal 123. the PN provides cold packs to the perineum of a postpartum client with perineal hematoma. What will the PN do to evaluate the effectiveness of this action? observe the hematoma for changes in size 124. A client has sustained a burn affecting the clients adipose tissue and blood vessels. Which layer of the clients skin has been affected by the burn? subcutaneous layer 125. During the assessment go a school age child the PN determines that the client is in Ericksons developmental stage of industry vs inferiority. Which behavior did the client demonstrate? sitting quietly reading a book ANSWER SHEET 2019 HESI EXIT PN TEST BANK 126. Flow Sheet 127. Date Hr 1 Hr 2 Hr 3 128. Pad count 2 3 2 129. Urine output 45 mL 35 mL 40 mL 130. TAB 3 - Laboratory Results 131. Date Laboratory Test Results 132. Bilirubin level newborn 14 mg/dL 133. Indirect Coombs' test mother Negative 134. Direct Coombs' test newborn Positive Administer Rh immune globulin 135. A client with type 1 diabetes mellitus has a morning fasting blood 136. glucose level of 70 mg/dL. Which action would the practical nurse take? nothing since this is considered a normal blood glucose level 137. A client with a bee sting has a respiratory rate of 28 and an oxygen 138. saturation level of 80% on room air. What action would the practical nurse 139. take at this time? notify the HCP and prepare to administer O2 140. A school-aged child is given a varicella zoster immune globulin 141. injection. The practical nurse realizes this client has which chronic illness? AIDS 142. The practical nurse positions a client with face and neck burns supine 143. with the neck extended and resting on a rolled towel. Why is this position 144. beneficial to the client? it maximizes neck and face function 145. An obese client asks why a high-protein diet will not help reduce her 146. elevated cholesterol level. What would the practical nurse respond to this 147. client? A high protein diet consist of meat, poultry, and dairy products which are all high in cholesterol 148. A client with an external urinary catheter is complaining of pain. What 149. would the practical nurse do to help this client? remove the external device 150. The lips and mucous membranes of an African-American client are 151. dusty in color. What does this assessment finding suggest to the practical 152. nurse? low oxygen level 153. A client with terminal cancer of the liver wants to leave the hospital and 154. spend time at home before dying. Which action would the practical nurse 155. take to help this client? talk withe the HCP regarding hospice care for the client 156. A client is prescribed a treatment in which the process of filtration will 157. be used. How will the practical nurse explain this cellular transport 158. mechanism to the client? 159. p mechanical pressure forces water and solutes through the membrane 160. A client has an infiltrated intravenous access device in the right arm. To 161. evaluate blood flow to this extremity, which arteries will the practical nurse 162. assess? (Select all that apply.) Brachial 163. radial 164. ulnar 165. The charge nurse is making client care assignments on a busy medicalsurgical 166. care area. Which client would be appropriate to assign to the 167. practical nurse? client recovering from a stroke needing subcutaneous heparin and gastrostomy feedings 168. Prior to administering a prescribed tube feeding to a client with a 169. gastrostomy tube why would the practical nurse aspirate for gastric 170. residual volume? the evaluate the amount of gastric emptying 171. A client is scheduled for an electroencephalogram (EEG). What will the 172. practical nurse instruct the client about this diagnostic test A? you will have electrodes placed on your scalp on your scalp during the test 173. Which action would the practical nurse take to evaluate the hydration 174. status of an infant recovering from abdominal surgery? weigh diapers and assess urine specific gravity 175. A client is prescribed dexamethasone (Decadron) 8 mg by mouth with 176. breakfast. The medication is n contact the pharmacy and ask that the medication be delivered now 177. A client has had a procedure that will result in scarring of the cervix. 178. How will the effects of the procedure impact the client's ability to achieve 179. pregnancy in the future? Restrict the fertilization of the ovum 180. photo of a blood pressure cuff on a clients arm. What would you tell the person palpate the brachial pulse which is on the inside of the arm 181. the PN is preparing to remove an indwelling urinary catheter in a female client. Which action would the PN perform first? deflate the balloon on the catheter 182. Why would the PN provide a bronchodilator to a client with asthma prior to conducting postural drainage? to mobilize secretions 183. There will be pictures of ECG select the one that looks like a bunch of M's 184. Patient has carotid endarterectomy how to observe for signs of bleeding? check area around the neck and elbow 185. pregnant lady reports greenish discharge from vagina nurse should advise the to test for Gonorrhea 186. When repositioning patient the nurse observes wound with a foul odor the nurse should... check the white blood cell count 187. this will be a prioritizing question of which patient to see first the patient with bright red drainage coming out of anus after colonoscopy and polyp 188. patient with dementia is admitted to the unit and is very agitated during the night put patient in room next to nursing station 189. UAP delegations -applying a condom catheter 190. -applying a hearing aid 191. -applying cold packs 192. 193. 194. 195. 196. 197. 198. 199. 200. -assisting to deep breath and cough -blood glucose monitoring -collecting specimens -emptying drainage containers -giving a sitz bath -vaginal douche -recording intake/output -removing a Foley catheter -taking specimens to the lab