HESI Critical Care RN Exit Exam Actual
Exam Questions And Answers Practice
Questions with Solutions Newest |
Already Graded A+
Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse?
Nulliparity
Early menarche
Multiple sexual partners
Hormone-replacement therapy - Correct Answer -Multiple sexual partners
Rationale: Risk factors for cervical cancer include multiple sexual partners, a history of human
papillomavirus infection, first sexual intercourse before the age of 16, cigarette smoking, environmental
tobacco smoke exposure, and use of oral contraceptives for more than 5 years. Nulliparity, early
menarche, and the use of hormone-replacement therapy are risk factors for ovarian rather than cervical
cancer.
A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse
interpret this finding?
Umbilical cord compression
Pressure on the fetal head during a contraction
Uteroplacental insufficiency during a contraction
Inadequate pacemaker activity of the fetal heart - Correct Answer -Uteroplacental insufficiency during a
contraction
Rationale: The observation that the nurse noted in this tracing is late decelerations. Late decelerations
constitute an ominous pattern in labor because they suggest uteroplacental insufficiency, possibly
associated with a contraction. Early decelerations result from pressure on the fetal head during a
1
,contraction. Variable decelerations suggest umbilical cord compression. The term short-term variability
refers to the difference between successive heartbeats, indicating that the natural pacemaker function
of the fetal heart is working properly.
A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume
sexual intercourse. What does the nurse tell the client about when sexual intercourse can be resumed?
At any time after the surgery
When menstruation resumes
When pelvic sensation and response to stimuli return
In about 6 weeks, when the vaginal vault is satisfactorily healed - Correct Answer -In about 6 weeks,
when the vaginal vault is satisfactorily healed
Rationale: After abdominal hysterectomy, the client is instructed to avoid sexual intercourse until the
vaginal vault is satisfactorily healed. This takes about 6 weeks. A woman who has undergone this
procedure must adjust to changes in the nature of pelvic sensations and stimuli during sexual
intercourse; however, this is not related to when sexual intercourse may be resumed. The client will not
have menstrual periods after abdominal hysterectomy.
A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment
of endometrial cancer. What does the nurse determine is the priority in the 24 hours after surgery?
Monitoring the client for signs of returning peristalsis
Instructing the client in dietary changes to prevent constipation
Encouraging the client to deep-breathe, cough, and use an incentive spirometer
Encouraging the client to talk about the effects of the surgery on her femininity and sexuality - Correct
Answer -Encouraging the client to deep-breathe, cough, and use an incentive spirometer
Rationale: The nurse determines that the priority in the 24 hours after surgery is to encourage the client
to deep-breathe, cough, and use an incentive spirometer. Care after abdominal hysterectomy includes
maintenance of a patent airway, promotion of circulation and oxygenation, promotion of comfort,
monitoring of output and drainage, promotion of elimination, and discharge teaching with regard to
medications and therapeutic regimens. The priority is the maintenance of a patent airway and
promotion of oxygenation and circulation. Monitoring the client for signs/symptoms of returning
2
,peristalis, instructing her in dietary habits to prevent constipation, and encouraging her to talk about the
effects of her surgery are also components of care after this surgery but are of lower priority than
encouraging the client to deep-breathe, cough, and use an incentive spirometer.
A nurse is caring for a client with community-acquired pneumonia who is being treated with
levofloxacin. Which finding, indicating an adverse reaction to the medication, does the nurse monitor
the client?
Fever
Dizziness
Flatulence
Drowsiness - Correct Answer -Fever
Rationale: Levofloxacin is an antibiotic of the fluoroquinolone class. Pseudomembranous colitis is an
adverse reaction associated with the use of this medication. It is characterized by severe abdominal pain
or cramps, severe watery diarrhea, and fever. Dizziness, flatulence, and drowsiness are side effects of
the medication.
A nurse is providing instructions to a client with glaucoma who will be using acetazolamide daily. Which
finding, an adverse effect, does the nurse instruct the client to report to the primary health care
provider?
Nausea
Dark urine
Urinary frequency
Decreased appetite - Correct Answer -Dark urine
Rationale: Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity may
occur, manifesting as dark urine and stools, lower back pain, jaundice, dysuria, crystalluria, renal colic,
and calculi. Bone marrow depression may also occur as an adverse effect. Nausea, urinary frequency,
and decreased appetite are side effects of the medication.
3
, 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?
Frequent suctioning
Maintaining cuff pressure
Maintaining mechanical ventilation settings
Alternating the use of a cuffed tube with a cuffless tube on a daily basis - Correct Answer -Maintaining
cuff pressure
Rationale: Necrosis of the tracheal wall caused by pressure of the cuff of an endotracheal tube can lead
to the development of an opening between the posterior trachea and esophagus, a complication known
as tracheoesophageal fistula. The fistula allows air to escape into the stomach, resulting in abdominal
distention. It also leads to the aspiration of gastric contents. To prevent this complication, the nurse
must maintain cuff pressure, monitor the amount of air needed for cuff inflation, and help the client
progress to a deflated cuff or cuffless tube as soon as possible as prescribed by the primary health care
provider. Suctioning should be performed only as needed; frequent suctioning can cause mucosal
damage. Maintenance of mechanical ventilation settings ensures that the client is adequately
oxygenated, but this intervention is not a measure for the prevention of tracheoesophageal fistula.
Alternating the use of a cuffed tube and a cuffless tube on a daily basis is incorrect, because the
endotracheal tube would not be removed and replaced on a daily basis.
Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does
the nurse implement? Select all that apply.
Keeping the room slightly darkened
Placing the client in a room with a quiet roommate
Encouraging isometric exercises if bed rest is prescribed
Monitoring the client for changes in alertness or mental status
Restricting visits to close family members and significant others and keeping visits short - Correct
Answer -Keeping the room slightly darkened
Monitoring the client for changes in alertness or mental status
Restricting visits to close family members and significant others and keeping visits short
4
Exam Questions And Answers Practice
Questions with Solutions Newest |
Already Graded A+
Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse?
Nulliparity
Early menarche
Multiple sexual partners
Hormone-replacement therapy - Correct Answer -Multiple sexual partners
Rationale: Risk factors for cervical cancer include multiple sexual partners, a history of human
papillomavirus infection, first sexual intercourse before the age of 16, cigarette smoking, environmental
tobacco smoke exposure, and use of oral contraceptives for more than 5 years. Nulliparity, early
menarche, and the use of hormone-replacement therapy are risk factors for ovarian rather than cervical
cancer.
A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse
interpret this finding?
Umbilical cord compression
Pressure on the fetal head during a contraction
Uteroplacental insufficiency during a contraction
Inadequate pacemaker activity of the fetal heart - Correct Answer -Uteroplacental insufficiency during a
contraction
Rationale: The observation that the nurse noted in this tracing is late decelerations. Late decelerations
constitute an ominous pattern in labor because they suggest uteroplacental insufficiency, possibly
associated with a contraction. Early decelerations result from pressure on the fetal head during a
1
,contraction. Variable decelerations suggest umbilical cord compression. The term short-term variability
refers to the difference between successive heartbeats, indicating that the natural pacemaker function
of the fetal heart is working properly.
A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume
sexual intercourse. What does the nurse tell the client about when sexual intercourse can be resumed?
At any time after the surgery
When menstruation resumes
When pelvic sensation and response to stimuli return
In about 6 weeks, when the vaginal vault is satisfactorily healed - Correct Answer -In about 6 weeks,
when the vaginal vault is satisfactorily healed
Rationale: After abdominal hysterectomy, the client is instructed to avoid sexual intercourse until the
vaginal vault is satisfactorily healed. This takes about 6 weeks. A woman who has undergone this
procedure must adjust to changes in the nature of pelvic sensations and stimuli during sexual
intercourse; however, this is not related to when sexual intercourse may be resumed. The client will not
have menstrual periods after abdominal hysterectomy.
A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment
of endometrial cancer. What does the nurse determine is the priority in the 24 hours after surgery?
Monitoring the client for signs of returning peristalsis
Instructing the client in dietary changes to prevent constipation
Encouraging the client to deep-breathe, cough, and use an incentive spirometer
Encouraging the client to talk about the effects of the surgery on her femininity and sexuality - Correct
Answer -Encouraging the client to deep-breathe, cough, and use an incentive spirometer
Rationale: The nurse determines that the priority in the 24 hours after surgery is to encourage the client
to deep-breathe, cough, and use an incentive spirometer. Care after abdominal hysterectomy includes
maintenance of a patent airway, promotion of circulation and oxygenation, promotion of comfort,
monitoring of output and drainage, promotion of elimination, and discharge teaching with regard to
medications and therapeutic regimens. The priority is the maintenance of a patent airway and
promotion of oxygenation and circulation. Monitoring the client for signs/symptoms of returning
2
,peristalis, instructing her in dietary habits to prevent constipation, and encouraging her to talk about the
effects of her surgery are also components of care after this surgery but are of lower priority than
encouraging the client to deep-breathe, cough, and use an incentive spirometer.
A nurse is caring for a client with community-acquired pneumonia who is being treated with
levofloxacin. Which finding, indicating an adverse reaction to the medication, does the nurse monitor
the client?
Fever
Dizziness
Flatulence
Drowsiness - Correct Answer -Fever
Rationale: Levofloxacin is an antibiotic of the fluoroquinolone class. Pseudomembranous colitis is an
adverse reaction associated with the use of this medication. It is characterized by severe abdominal pain
or cramps, severe watery diarrhea, and fever. Dizziness, flatulence, and drowsiness are side effects of
the medication.
A nurse is providing instructions to a client with glaucoma who will be using acetazolamide daily. Which
finding, an adverse effect, does the nurse instruct the client to report to the primary health care
provider?
Nausea
Dark urine
Urinary frequency
Decreased appetite - Correct Answer -Dark urine
Rationale: Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity may
occur, manifesting as dark urine and stools, lower back pain, jaundice, dysuria, crystalluria, renal colic,
and calculi. Bone marrow depression may also occur as an adverse effect. Nausea, urinary frequency,
and decreased appetite are side effects of the medication.
3
, 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?
Frequent suctioning
Maintaining cuff pressure
Maintaining mechanical ventilation settings
Alternating the use of a cuffed tube with a cuffless tube on a daily basis - Correct Answer -Maintaining
cuff pressure
Rationale: Necrosis of the tracheal wall caused by pressure of the cuff of an endotracheal tube can lead
to the development of an opening between the posterior trachea and esophagus, a complication known
as tracheoesophageal fistula. The fistula allows air to escape into the stomach, resulting in abdominal
distention. It also leads to the aspiration of gastric contents. To prevent this complication, the nurse
must maintain cuff pressure, monitor the amount of air needed for cuff inflation, and help the client
progress to a deflated cuff or cuffless tube as soon as possible as prescribed by the primary health care
provider. Suctioning should be performed only as needed; frequent suctioning can cause mucosal
damage. Maintenance of mechanical ventilation settings ensures that the client is adequately
oxygenated, but this intervention is not a measure for the prevention of tracheoesophageal fistula.
Alternating the use of a cuffed tube and a cuffless tube on a daily basis is incorrect, because the
endotracheal tube would not be removed and replaced on a daily basis.
Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does
the nurse implement? Select all that apply.
Keeping the room slightly darkened
Placing the client in a room with a quiet roommate
Encouraging isometric exercises if bed rest is prescribed
Monitoring the client for changes in alertness or mental status
Restricting visits to close family members and significant others and keeping visits short - Correct
Answer -Keeping the room slightly darkened
Monitoring the client for changes in alertness or mental status
Restricting visits to close family members and significant others and keeping visits short
4
