HESI RN EXIT V1 2022

HESI RN EXIT V1 2022

117. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.” The nurse should understand that A) A referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medicationsC) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects The correct answer is B: The client has a right to know about the prescribed medications 118. Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time? A) ”Have the client sit on the side of the bed for at least 2 minutes before helping him stand." B) ”If the client is dizzy on standing, ask him to take some deep breaths." C) ”Assist the client to the bathroom at least twice on this shift." D) ”After you assist him to the chair, let me know how he feels."The correct answer is A: "Have the client sit on the side of the bed for at least 2 minutes before helping him stand." 119. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client A) Has had a change in respiratory rate by an increase of 2 breaths B) Has had a change in heart rate by an increase of 10 beats C) Was minimally responsive to voice and touch D) Has had a blood pressure change by a drop in 8 mmHg systolic The correct answer is C: Was minimally responsive to voice and touch 120. A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is A) ”I must document and report any information." B) ”I can’t make such a promise." C) ”That depends on what you tell me." D) ”I must report everything to the treatment team." The correct answer is B: "I can’t make such a promise." 121. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A) Be with a client who self-administers insulin B) Cleanse and dress a small decubitus ulcer C) Monitor a client's response to passive range of motion exercises D) Apply and care for a client's rectal pouch The correct answer is D: Apply and care for a client''s rectal pouch 122. A client asks the nurse to call the police and states: “I need to report that I am being abused by a nurse.” The nurse should first A) Focus on reality orientation to place and person B) Assist with the report of the client’s complaint to the police C) Obtain more details of the client’s claim of abuse D) Document the statement on the client’s chart with a report to the manager The correct answer is C: Obtain more details of the client’s claim of abuse 123. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with A) A Dopamine drip IV with vital signs monitored every 5 minutes B) A myocardial infarction that is free from pain and dysrhythmias C) A tracheotomy of 24 hours in some respiratory distress D) A pacemaker inserted this morning with intermittent capture The correct answer is B: A myocardial infarction that is free from pain and dysrhythmias 124. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? A) ”How long have you been a UAP and what units you have worked on?" B) ”What type of care do you give on the surgical unit and what ages of clients?" C) “What is your comfort level in caring for children and at what ages?" D) ”Have you reviewed the list of expected skills you might need on this unit?" The correct answer is D: "Have you reviewed the list of expected skills you might need on this unit?" 125. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to A) Ask to not be assigned to this client or to work on another unit B) Tell the client that such behavior is inappropriate C) Inform the client that hospital policy prohibits staff to date clients D) Discuss the boundaries of the therapeutic relationship with the clientThe correct answer is D: Discuss the boundaries of the relationship with the client 126. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? A) To observe the type and amount of nasogastric tube drainage B) Monitor the client for nausea or other complications C) Irrigate the nasogastric tube with the ordered irrigate D) Perform nostril and mouth care The correct answer is D: Perform nostril and mouth care 127. The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)? A) Test blood sugar every 2 hours by accu check B) Review with family and client signs of hyperglycemia C) Monitor for mental status changes D) Check skin condition of lower extremities Review Information: The correct answer is A: Test blood sugar every 2 hours by accucheck 128. A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP? A) A 76-year-old client with severe depression B) A middle-aged client with an obsessive compulsive disorder C) A adolescent with dehydration and anorexia D) A young adult who is a heroin addict in withdrawal with hallucinationsThe correct answer is B: A middle-aged client with an obsessive compulsive disorder 129. The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees F for a post surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? A) Encourage oral fluids for the temperature elevation B) Check temperature 15 minutes after hot liquids are taken C) Ask the client to drink only cold water and juices D) Chart this temperature elevation on the flow sheet The correct answer is B: Check temperature 15 minutes after hot liquids are taken 130. A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to A) Keep the client’s room door cracked to minimize the distractions B) Assign 1 of the nursing staff to visit the client regularly C) Reassure the client that 1 staff person will check frequently if the clientneeds anything D) Arrange for each staff member to go into the client’s room to check on needs every hour on the hour The correct answer is B: Assign 1 of the nursing staff to visit the client regularly 131. A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? A) The results of a standardized tool that measures depression B) Observation of affect and behavior C) Inquiry about use of alcohol D) Family history of emotional problems or mental illness The correct answer is B: Observation of affect and behavior 132.