HESI Exit Actual Final Exam

HESI Exit Actual Final Exam 1. The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take?: Leave the cuff inflated and suction through the tracheostomy. 2. A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate?: Assess oxygen saturation levels. 3. The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask?: "Have you ever had chest pain?" 4. The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take?: Ask the client to describe the pain. Assessment: outcome priority; must validate that client is in pain before implementation 5. A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate?: Place the client on her left side with her legs flexed. Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on inferior vena cava reduced 6. A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status?: Urinary output of 1,500 mL in 24 hours. Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased and concentrated 7. The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which medication should the nurse question giving to the client?: 40 mg oral furosemide (Lasix) in the morning. Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation; combination of vasodilation and diuresis increases risk of orthostatic hypotension 8. The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the nurse?: "I drove to the library yesterday." Implementation: outcome not desired and may be a problem; client is not able to turn with halo device; increases the risk of injury to self and others 9. The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement?: The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement? The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement? 10. The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appropriate?: A 38-year-old client with a diagnosis of systemic lupus erythematosus. Implementation: outcome desired; autoimmune disease; not infectious 11. The nurse in the outclient surgery unit prepares a 4- year-old child for surgery. It is MOST important for the nurse to make which of these statements?: "Take this doll and show me where the operation will be done." Implementation: outcome desired; encourage expression of feelings (e.g., anger); fear mutilation; allow child to play with models of equipment 12. The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and incontinent of urine. What is the MOST important action for the nurse to take?: Assist the client to a bedside commode every 2 hours. Implementation: outcome desired; keeps client active and independent 13. The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the surgical acute- care unit after a right below-knee amputation. The client's capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should be administered. Which of the following is the FIRST action the nurse should take?: Administer the 6 units of regular insulin Implementation: outcome desired; sliding scale-receives predetermined amount of insulin according to glucose level; surgery and infection increase insulin needs 14. During the admission interview, the client reports a red, itchy raised rash on the chest and lip swelling after use of aspirin and penicillin. The admission orders include bed rest, soft diet as tolerated, naproxen (Naprosyn), and cefaclor (Ceclor). Which is the BEST description of expected breath sounds heard during auscultation?: Do not administer the Ceclor or naproxen; notify the healthcare provider. Implementation: outcome desired; both medications should be withheld; risk of hypersensitivity reaction 15. The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further teaching is needed?: "I should take polyethylene glycol (MiraLax) with a large glass of water." Implementation: outcome not desired; osmotic laxative and is contraindicated; avoid enteric-coated or capsule medication, which may not be absorbed through GI tract 16. The nurse cares for a client diagnosed with chronic bronchitis and peripheral vascular disease. The nurse expects to assess which of these breath sounds?: Deep, low-pitched rumbling sounds are heard mainly on expiration. Assessment: outcome expected; sonorous wheezes or rhonchi, caused by mucus in the airways; excessive mucous production is primary symptom 17. The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old client. Which is the MOST important action for the nurse to take prior to administration of the medication?: Monitor the serum BUN and creatinine. Assessment: outcome priority; nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance 18. The nurse cares for the client in the labor unit. During the transitional phase of labor, the umbilical cord becomes prolapsed. It is MOST important for the nurse to take which action?: Place the client supine with the foot of the bed elevated. Implementation: outcome desired; Trendelenburg or knee chest position desired to decrease pressure on umbilical cord 19. The nurse cares for the client diagnosed with lung cancer. The family states that the client has become confused and that urinary output has decreased during the previous 24 hours. Which finding MOST concerns the nurse?: Sodium 128 mEq/L. Assessment: outcome desired and priority; normal sodium range is 135-145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically depressed with increased risk of seizures 20. The home care nurse cares for a client who is diagnosed with hypertension and mild depression. The client's daughter states that her mother has been falling frequently. WWhich response by the nurse is BEST?: "When does your mother fall?" Assessment: outcome priority; nurse needs to determine what the problem is before implementing; recent history of falling is most important contributor to increased risk of falls 21. A femoral angiogram is scheduled for a client. It is MOST important for the nurse to take which action prior to the angiogram?: Locate and note the presence of peripheral pulses. Assessment: outcome desired and priority; pulse location may be marked according to facility policy; important to get baseline assessment of color, motion, temperature and sensitivity of extremities as well as strength and equality of pulses 22. A child sustains a crushing chest injury in a car accident. In the emergency room, an endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the child in respiratory distress. It is MOST important for the nurse to take which action prior to the angiogram?: Listen to the client's breath sounds. Assessment: outcome priority; will give early and clearest indication of respiratory status, will hear changes with narrowed airways, fluid in alveoli or pneumothorax 23. The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST important for the nurse to take which action?: . Frequently inform the client of the room and bathroom location. Implementation: outcome desired; provides for safety needs and frequent orientation 24. The nurse is responsible for triage of injured residents of an apartment building that collapsed during a tornado. Which client should the emergency personnel see FIRST?: A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute, irregular respirations at 12/minute. Real problem; vitals signs indicate significant increase in intracranial pressure; most unstable client 25. The nurse cares for a client diagnosed with Crohn's disease. The nurse instructs the client about diet. Which menu selection indicates to the nurse that teaching is effective?: Baked cod, biscuit without butter, fruit roll-up. Implementation: outcome desired; low-fat, high-protein, low- residue, nonirritating, high in calories, minerals 26. The nursing team consists of one RN, one LPN/LVN and two nursing assistive personnel (NAPs). Which assignment is MOST appropriate for the LPN/LVN?: A 78-year-old client diagnosed with a thrombotic cerebrovascular accident 5 days Outcome desired; LPN/LVN can care for stable clients with expected outcomes; nothing in question indicates instability; as cerebral edema resolves, the condition will improve 27. The nurse cares for a client during a 24-hour urine specimen collection. Several hours later, the client tells the nurse that she has started to menstruate. Which action by the nurse is MOST appropriate?: Inform the health care provider that the client is menstruating.2. Send the urine collected prior to the onset of the client's menstruation to the lab. Implementation: outcome desired; menstruation may last several days to a week; protein and red cells may alter the results of the urinalysis 28. The nurse cares for the client in the recovery room after a knee surgery procedure. The client has an oral airway in place. Which is the BEST indicator that the oral airway can be removed?: The client tries to chew on the oral airway.. Assessment: outcome priority; client is alert and able to maintain his own airway 29. The nurse cares for clients in the antepartum clinic. Which client should the nurse see FIRST? 1. An 18-year-old multigravida client at 28 weeks gestation with a positive indirect Coombs' test. 2. A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema. 3. A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate. 4. A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of fetal movement.: A 24- year-old multigravida client at 32 weeks gestation with moderate facial edema. A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema. 30. The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix), spironolactone (Aldactone), and a low-sodium diet. Which statement by the client indicates the need for further instruction? 1. "I should weigh myself every morning and call the health care provider if I gain more than a couple of pounds in a few days." 2. "I should call the health care provider immediately if I start to feel nauseated or have difficulty breathing with normal activities." 3. "I plan to use salt substitutes now that I have to limit my sodium intake."4. "I should read food and nonprescription medication labels to check the ingredients.": "I plan to use salt substitutes now that I have to limit my sodium intake." Implementation: outcome not desired; salt substitutes contain potassium; spironolactone is a potassium-sparing diuretic 31. The nurse cares for a client scheduled for a femoral popliteal bypass procedure. When the nurse approaches the client with the informed consent form, the client says, "I don't need to talk to anybody about this procedure. I already know everything I need to know about it." Which response by the nurse is BEST?1. "After I explain the operation to you, both of us will sign the form for legal purposes and it will be placed in your chart."2. "Tell me what the healthcare provider told you about the risks and benefits of this operation."3. "Can I answer any questions that you have about the procedure?"4. "You should read all these materials to be sure that you understand everything about this procedure." 1) Implementation: outcome not desired; nurse should not explain the procedure; the health care provider doing the procedure should explain the risks and benefits2) CORRECT - Assessment: outcome desired; nurse should determine if client understands risks and benefits of the procedure before the client and nurse sign the informed consent form3) Implementation: outcome not desired; yes/no question non- therapeutic response4) Implementation: outcome desired but not priority; reading materials do not ensure that client understands risks and benefits of the procedure A man scheduled for a vasectomy tells the nurse that he and his wife are involved in a monogamous relationship. Which statement by the nurse is BEST? 1. "You will need to wear a condom when having sexual