IHP HESI RN EXIT EXAM ANSWERS

IHP HESI RN EXIT EXAM ANSWERS

A 12 year old child with acute episode of asthma receives a rx for albuterol via nebulization to be followed by pirbuterol autoinhaler. Which assessment finding should the nurse report to the healthcare provider before administering the pirbuterol? PALPATIONS AND BLOOD PRESSURE CHANGES The nurse is caring a client with nasogastric (NG) tube. Which task can the nurse delegate to the UAP? DISCONNECT THE NG SUCTION SO THE CLIENT CAN AMBULATE IN THE HALLWAY In completing the treatment plan for an 11 year old who has bipolar disorder, the nurse plans outcomes for the nursing diagnosis, “Risk for violence towards peers related to impulsivity.” Which outcome is most important? TELLS STAFF WHEN THOUGHTS OF HARMING OTHERS OCCUR The mother of an 8- month old with a medical dx of rotavirus tells the nurse that her child has had watery diarrhea for the last 2 or 3 days. Which assessment data supports the hx provided by the mother? DARK AMBER URINE IN SCANTY AMOUNTS Following a punch bx, a woman with AIDS is dx with cutaneous Kaposis sarcoma she tells the nurse that she knows this means she is in the final stages of the disease. What should the nurse provide? DESCRIBE TREATMENT OPTIONS FOR THIS STAGE AND SITE MORTALITY RATES The nurse is admitting a male client to the rehabilitation unit who us paraplegic and has an indwelling urinary catheter. Which nursing outcome is most important to include in the clients plan of care? FEBRILE URINARY INFECTIONS ARE ABSENT The nurse observes a UAP begin to provide oral care to an unresponsive client who is at risk for aspiration as seen in the picture. What instructions should the nurse provide to the UAP ? ELEVATE THE HEAD OF THE BED TURN THE CLIENTS HEAD TO THE SIDE Based on the principles of asepsis, the nurse should consider which circumstances to be sterile? AN OPEN STERILE FOLEY CATHETER KIT SET UP ON A TABLE AT THE NURSES WAIST LEVEL A older male who is admitted with end stage COPD tells the nurse that his family wants CPR to be provided if the need arises. The client provides the nurse with a living will and a advanced directive that specifies DNR. What action should the nurse implement? OBTAIN A RX FOR DNR The nurse is conducting the initial assessment of an ill client who is from another culture. To effectively care for this client, which response should the nurse provide? “WHAT PRACTICES DO YOU BELIEVE WILL HELP YOU HEAL” A male hospice client on a palliative care unit is no longer able to swallow and is becoming dehydrated. The client tells the nurse that he does not want to receive intravenous fluids or tube feedings. What action should the nurse implement? PROVIDE COMFORT MEASURES TO REDUCE DISCOMFORT MEASURES WITH DEHYDRATION A client is admitted to the isolation with the diagnosis of active TB. Which infection control measures should the nurse implement? NEGATIVE PRESSURE ENVIRONMENT A client whose wrist is sutured from a recent suicide attempt is being transferred from a medical unit to the psychiatric unit. Which nursing dx is of the highest priority? RISK FOR SELF DIRECTED VIOLENCE RELATED TO IMPULSIVE ACTIONS To obtain an estimate of a client’s systolic blood pressure, what action should the nurse take first? PALPATE THE CLIENT BRACHIAL PULSE A nurse determines that more than 25% of the students at a middle school are overweight, and presents the information at a parent teacher meeting. What action is most important for the nurse to include in the meeting? DETERMINES THE PARENTS DEGREE OF CONCERN ABOUT THEIR CHILDERNS WEIGHT A young woman who is hypovolemic due to several months of heavy menstrual bleeding is reciving a unit of red pack blood cells while preparing to have a dilation and curettage (D&C0). Which assessment findings warrant immediate intervention by the nurse? ITCHING WITH A FINE RED RASH A woman who just receive the rubella vaccine after delivery of a normal newborn has two children at home, ages 13 months and 3 years. Which instruction is most important for the nurse to provide to this client? DO NOT GET PREGNANT FOR THE NEXT 3 MONTHS During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiates a thrombolytic infusion through the sheath to dissolve an occluded artery. Which intervention should the nurse implement? INSTRUCT THE CLIENT TO KEEPLEFT LEG STRAIGHT OBSERVE THE INSERTION SITE FOR A HEMATOMA CIRCLE FIRST NOTED DRAINAGE ON THE DRESSING Based on the principals of asepsis the nurse should consider which circumstances to be sterile? AN OPEN STERILE FOLEY CATHTER KIT KEPT OPEN AT THE NUSRES WAIST LEVEL After changing to a brand new laundry detergent, an adult male reports that he has a fine itchy rash. Which assessments findings warrants immediate intervention by the nurse? BILATERAL WHEEZING