HESI 799 RN Exit Exam Part 1 Of 2 - 125 Study
Set With Complete Solutions
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse
(PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse
assign to the RN?
a. Supervise a newly hired graduate nurse during an admission assessment.
b. Transport a client who is receiving IV fluids to the radiology department.
c. Administer PRN oral analgesics to a client with a history of chronic pain
d. Complete ongoing focused assessments of a client with wrist restrain. - ANSWER
Supervise a newly hired graduate nurse during an admission assessment.
Rationale: The admission assessment of a client should be completed by a professional
nurse. A graduate nurse should be supervised by the RN to ensure that the graduate
nurse understand and performs within the expected scope of practice. The UAP
transport a stable client. (B) The PN can complete C and D
While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the
client stares into the distance and appears to be concentrating on something other than
the lesson the nurse is presenting. What action should the nurse take
a. Remind the client that a rescue inhaler might save his life
b. Leave the client alone so that he can grieve his illness
c. Ask the client what he is thinking about at his time.
d. Gently touch the client then continue with teaching. - ANSWER Ask the client what he
is thinking about at his time.
After several hours of non-productive coughing, a client presents to the emergency
room complaining of chest tightness and shortness of breath. History includes end
stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While
completing the pulmonary assessment, the nurse hears wheezing and poor air
movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
,a. Apply oxygen via nasal cannula
b. Administer PRN nebulizer treatment.
c. Obtain 12 lead electrocardiogram.
d. Monitor continuous oxygen saturation.
e. Give PRN dose of regular insulin - ANSWER b. Administer PRN nebulizer treatment.
c. Obtain 12 lead electrocardiogram.
d. Monitor continuous oxygen saturation.
Rationale: A nebulizer treatment may improve the wheezing. Chest tightness is most
likely to coughing, but a 12-lead electrocardiogram is needed to assess for cardiac
ischemia. Oxygen saturation monitors for adequate oxygenation.
The nurse caring for a 3-month-old boy one day after a pylorostomy notices that the
infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest.
What action should the nurse take?
a. Administer a prescribed analgesia for pain.
b. Increase IV infusion rate for rehydration
c. Provide additional blankets to increase body temperature
d. Feed one ounce of formula to correct hypoglycemia. - ANSWER Administer a
prescribed analgesia for pain
Rationale: Since this child is exhibiting signs of pain, the prescribed analgesic should be
administered. The behavioral signs of pain in an infant are facial grimaces, restlessness
or agitation, and guarding the area of pain, in this case by pulling the knees to the chest
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT)
protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which
information should the nurse provide the parents about caring for their child?
A. Use sunblock or protective clothing when outdoors - ANSWER Use sunblock or
,protective clothing when outdoors
Two days after admission a male client remembers that he is allergic to eggs, and
informs the nurse of the allergy. Which actions should the nurse implement? (Select all
that apply)
a. Notify the food services department of the allergy.
b. Enter the allergy information in the client's record.
c. Document the statement in the nurse's notes
d. Note the allergy on the diet intake flow sheet
e. Add egg allergy to the client's allergy arm band. - ANSWER a. Notify the food services
department of the allergy.
b. Enter the allergy information in the client's record.
e. Add egg allergy to the client's allergy arm band.
Rationale: The dietary department needs to screen menu selections for foods that are
prepared with eggs. The client's chart should be clearly marked but the statement does
not need to be documented in the nurse's note or included in the intake record. Allergy
identification on the arm band is a universal location where allergies are noted while
client is hospitalized.
The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min
of continuous chest compressions. The client has a weak, fast pulse and no respiratory
effort, so the healthcare provider performs a successful oral, intubation. What action
should the nurse implement?
a. Perform bilateral chest auscultation.
b. Resume compression for 2 minutes
c. Administer a dose of epinephrine
d. Program the monitor for cardioversion. - ANSWER Perform bilateral chest
auscultation
, Rationale: With the ROSC and no respiratory effort intubation is indicated, and as soon
as the procedure is completed, the position of the intubation tube should be assessed
for proper placement. Auscultating for breath sounds is the first and quickest method to
use to check for proper placement of the intubation tube and can be confirmed by a
chest x ray.
After administering an antipyretic medication. Which intervention should the nurse
implement?
A. Encouraging liberal fluid intake - ANSWER Encouraging liberal fluid intake
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which
explanation should be included in preparing this client for this treatment?
a. Explain the need for using lead shields for 2 to 3 weeks after the treatment
b. Describe the signs of goiter because this is a common side effect of radioactive
iodine
c. Explain that relief of the signs/symptoms of hyperthyroidism will occur immediately
d. Describe radioactive iodine as a tasteless, colorless medication administered by the
healthcare provider - ANSWER Describe radioactive iodine as a tasteless, colorless
medication administered by the healthcare provider
Rationale: A single dose of tasteless, colorless radioactive iodine is administered by
mouth and the client is observed for signs of thyroid storm. 85% of clients are cure by
one dose. The dose of radioactivity is not enough to warrant (A). B is indicated for a
client receiving iodine or iodine compound medications in the treatment of
hyperthyroidism. It takes 3 to 4 weeks for sings of hyperthyroidism to subside.
After a colon resection for colon cancer, a male client is moaning while being
transferred to the Postanesthesia Care Unit (PACU). Which intervention should the
nurse implement first?
Set With Complete Solutions
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse
(PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse
assign to the RN?
a. Supervise a newly hired graduate nurse during an admission assessment.
b. Transport a client who is receiving IV fluids to the radiology department.
c. Administer PRN oral analgesics to a client with a history of chronic pain
d. Complete ongoing focused assessments of a client with wrist restrain. - ANSWER
Supervise a newly hired graduate nurse during an admission assessment.
Rationale: The admission assessment of a client should be completed by a professional
nurse. A graduate nurse should be supervised by the RN to ensure that the graduate
nurse understand and performs within the expected scope of practice. The UAP
transport a stable client. (B) The PN can complete C and D
While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the
client stares into the distance and appears to be concentrating on something other than
the lesson the nurse is presenting. What action should the nurse take
a. Remind the client that a rescue inhaler might save his life
b. Leave the client alone so that he can grieve his illness
c. Ask the client what he is thinking about at his time.
d. Gently touch the client then continue with teaching. - ANSWER Ask the client what he
is thinking about at his time.
After several hours of non-productive coughing, a client presents to the emergency
room complaining of chest tightness and shortness of breath. History includes end
stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While
completing the pulmonary assessment, the nurse hears wheezing and poor air
movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
,a. Apply oxygen via nasal cannula
b. Administer PRN nebulizer treatment.
c. Obtain 12 lead electrocardiogram.
d. Monitor continuous oxygen saturation.
e. Give PRN dose of regular insulin - ANSWER b. Administer PRN nebulizer treatment.
c. Obtain 12 lead electrocardiogram.
d. Monitor continuous oxygen saturation.
Rationale: A nebulizer treatment may improve the wheezing. Chest tightness is most
likely to coughing, but a 12-lead electrocardiogram is needed to assess for cardiac
ischemia. Oxygen saturation monitors for adequate oxygenation.
The nurse caring for a 3-month-old boy one day after a pylorostomy notices that the
infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest.
What action should the nurse take?
a. Administer a prescribed analgesia for pain.
b. Increase IV infusion rate for rehydration
c. Provide additional blankets to increase body temperature
d. Feed one ounce of formula to correct hypoglycemia. - ANSWER Administer a
prescribed analgesia for pain
Rationale: Since this child is exhibiting signs of pain, the prescribed analgesic should be
administered. The behavioral signs of pain in an infant are facial grimaces, restlessness
or agitation, and guarding the area of pain, in this case by pulling the knees to the chest
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT)
protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which
information should the nurse provide the parents about caring for their child?
A. Use sunblock or protective clothing when outdoors - ANSWER Use sunblock or
,protective clothing when outdoors
Two days after admission a male client remembers that he is allergic to eggs, and
informs the nurse of the allergy. Which actions should the nurse implement? (Select all
that apply)
a. Notify the food services department of the allergy.
b. Enter the allergy information in the client's record.
c. Document the statement in the nurse's notes
d. Note the allergy on the diet intake flow sheet
e. Add egg allergy to the client's allergy arm band. - ANSWER a. Notify the food services
department of the allergy.
b. Enter the allergy information in the client's record.
e. Add egg allergy to the client's allergy arm band.
Rationale: The dietary department needs to screen menu selections for foods that are
prepared with eggs. The client's chart should be clearly marked but the statement does
not need to be documented in the nurse's note or included in the intake record. Allergy
identification on the arm band is a universal location where allergies are noted while
client is hospitalized.
The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min
of continuous chest compressions. The client has a weak, fast pulse and no respiratory
effort, so the healthcare provider performs a successful oral, intubation. What action
should the nurse implement?
a. Perform bilateral chest auscultation.
b. Resume compression for 2 minutes
c. Administer a dose of epinephrine
d. Program the monitor for cardioversion. - ANSWER Perform bilateral chest
auscultation
, Rationale: With the ROSC and no respiratory effort intubation is indicated, and as soon
as the procedure is completed, the position of the intubation tube should be assessed
for proper placement. Auscultating for breath sounds is the first and quickest method to
use to check for proper placement of the intubation tube and can be confirmed by a
chest x ray.
After administering an antipyretic medication. Which intervention should the nurse
implement?
A. Encouraging liberal fluid intake - ANSWER Encouraging liberal fluid intake
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which
explanation should be included in preparing this client for this treatment?
a. Explain the need for using lead shields for 2 to 3 weeks after the treatment
b. Describe the signs of goiter because this is a common side effect of radioactive
iodine
c. Explain that relief of the signs/symptoms of hyperthyroidism will occur immediately
d. Describe radioactive iodine as a tasteless, colorless medication administered by the
healthcare provider - ANSWER Describe radioactive iodine as a tasteless, colorless
medication administered by the healthcare provider
Rationale: A single dose of tasteless, colorless radioactive iodine is administered by
mouth and the client is observed for signs of thyroid storm. 85% of clients are cure by
one dose. The dose of radioactivity is not enough to warrant (A). B is indicated for a
client receiving iodine or iodine compound medications in the treatment of
hyperthyroidism. It takes 3 to 4 weeks for sings of hyperthyroidism to subside.
After a colon resection for colon cancer, a male client is moaning while being
transferred to the Postanesthesia Care Unit (PACU). Which intervention should the
nurse implement first?
