HESI Comprehensive Exit Exam 2023 70. 70 After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client?
B. Insertion of an indwelling catheter
C. Administration of oxytocin (Pitocin)
D. Replacement of the uterus through the vagina into a normal position: D.
Replacement of the uterus through the vagina into a normal position
71. 71 A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would:
A. Notify the physician
B. Recheck the temperature in 4 hours
C. Encourage the client to breastfeed the newborn
D. Institute strict bedrest for the client and notify the physician: B. Recheck the temperature in 4 hours
72. 72 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be:
A. Documenting the findings
B. Encouraging the woman to walk
C. Helping the woman empty her bladder Correct
D. Massaging the fundus gently until it becomes firm: C. Helping the woman empty her bladder
73. 73-A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time?
A. Anxiety Correct
B. Premature grief
C. Fluid volume loss
D. Fluid volume overload: A. Anxiety
74. 74 -A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client?
A. Increased platelet count
B. Shortened prothrombin time
C. Positive result on d-dimer study
D. Decreased fibrin-degradation products: C. Positive result on d-dimer study 75. 75 -A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply.
A. Tachycardia Correct
B. Cool, clammy skin
C. Decreased respiratory rate
D. Diminished peripheral pulses Correct
E. Urine output of less than 30 mL/hr: A. Tachycardia Correct
D. Diminished peripheral pulses Correct
76. 76- A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock?
A. Checking the client's urine output
B. Inserting an intravenous (IV) line
C. Obtaining informed consent for a cesarean delivery
D. Placing the client in a lateral position with the bed flat: D. Placing the client in a lateral position with the bed flat
77. 77 -A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician?
A. Pink lochia on postpartum day 4
B. White lochia on postpartum day 11
C. Bloody lochia on postpartum day 2
D. Reddish lochia on postpartum day 8: D. Reddish lochia on postpartum day 8 78. 78 A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to:
A. Document the findings
B. Ask the physician to see the client immediately
C. Ask another nurse to check for the uterine fundus
D. Place the client in the supine position for 5 minutes, then recheck the abdome: A. Document the findings
79. 79- A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta?
A. "Many of my antibodies are passed through the placenta."
B. "The placenta maintains the body temperature of my baby."
C. "Glucose, vitamins, and electrolytes pass through the placenta."
D. "It provides an exchange of oxygen and carbon dioxide between me and my baby.": B. "The placenta maintains the body temperature of my baby."
80. 80 -A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is:
A. June 2, 2013
B. July 2, 2013
C. October 2, 2013
D. September 18, 2013: B. July 2, 2013
81. 81 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication?
D. Oranges: A. Steak
82. 82 -A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy?
A. Sodium 140 mEq/L
B. Hemoglobin 12.5 g/dL
C. Blood urea nitrogen (BUN) 20 mg/dL
D. White blood cell count of 2500 cells/mm3: D. White blood cell count of 2500 cells/mm3
83. 83 -Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse?
B. Early menarche
C. Multiple sexual partners Correct
D. Hormone-replacement therapy: C. Multiple sexual partners
84. 84 -A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding?
A. Umbilical cord compression
B. Pressure on the fetal head during a contraction
C. Uteroplacental insufficiency during a contraction Correct
D. Inadequate pacemaker activity of the fetal heart: C. Uteroplacental insufficiency during a contraction
85. 85- A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:
A. At any time after the surgery
B. When menstruation resumes
C. When pelvic sensation and response to stimuli return
D. In about 6 weeks, when the vaginal vault is satisfactorily healed: D. In about
6 weeks, when the vaginal vault is satisfactorily healed
86. 86 -A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is:
A. Monitoring the client for signs of returning peristalsis
B. Instructing the client in dietary changes to prevent constipation
C. Encouraging the client to deep-breathe, cough, and use an incentive spirometer Correct
D. Encouraging the client to talk about the effects of the surgery on her femininity and sexual: C. Encouraging the client to deep-breathe, cough, and use an incentive spirometer
87. 87- A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client?
D. Drowsiness: A. Fever
88. 88 -A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician?
B. Dark urine
C. Urinary frequency
D. Decreased appetite: B. Dark urine
89. 89 -A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement?
A. Frequent suctioning
B. Maintaining cuff pressure
C. Maintaining mechanical ventilation settings
D. Alternating the use of a cuffed tube with a cuffless tube on a daily basis: B. Maintaining cuff pressure
90. 90 - A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube?
91. 91 -Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply