HESI EXIT RN V3 QUESTIONS AND VERIFIED ANSWERS
LATEST UPDATE ASSURED PASS
A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer's solution at 75
mL/hour IV. One
hour after admission to the unit, the nurse notes 300 mL of blood in the suction
canister, the
client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In
addition to
reporting the finding to the surgeon. Which action should the nurse implement
first?
a. Measure and document the client's urinary output.
b. Request the client's reserved unit if packed red blood cells.
c. Prepare the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer's solution - ANS... -d. Increase the
infusion rate of Lactated Ringer's solution
an adult male who fell 20 feet from the roof of this home has multiple injuries,
including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his
transfer to
the intensive care unit (ICU). the nurse notes that the suction control chamber is
bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml
of bright red
blood is measured in the collection chamber. Which intervention should the nurse
implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as autotransfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in water seal - ANS... -a. Add
sterile water to the suction control chamber.
A client who received hemodialysis yesterday is experiencing a blood pressure of
200/100
,mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The
client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation
on room air
of 89%. Which action should the nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client's fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis. - ANS... -c. Begin supplemental oxygen.
A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation.
Based on the client's admitting diagnosis, which findings require immediate action
by the nurse?
(Select all that apply)
a. Headache and tremors
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis - ANS... -a. Headache and tremors
An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding
is the best indicator of hydration that the nurse should report to the healthcare
provider?
a. Urine specific gravity is 1.040
b. Systolic blood pressure decreases 10 points when standing.
c. The client denies being thirsty.
d. Skin tenting occurs when the client's forearm is pinched. - ANS... -d. Skin
tenting occurs when the client's forearm is pinched.
After an inservice about electronic health record (EHR) security and safeguarding
client
information, the nurse observes a colleague going home with printed copies of
client
information in a uniform pocket. Which action should the nurse take?
a. File a detailed incident report with the specific hiring facility.
b. Warn the colleague that their actions are unprofessional.
c. Comment anonymously about the action of a staff discussion board.
,d. Communicate the colleague's actions to the unit charge nurse - ANS... -a. File a
detailed incident report with the specific hiring facility.
The nurse is evaluating a tertiary prevention program for clients with
cardiovascular disease
implemented in a rural health clinic. Which outcome indicate the program is
effective?
a. At-risk clients received an increased number of routine health screenings.
b. Clients reported having new confidence in making healthy food choices.
c. Clients who incurred disease complications promptly received rehabilitation.
d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
- ANS... -c. Clients who incurred disease complications promptly received
rehabilitation.
The nurse is caring for a client with chronic obstructive pulmonary disease
(COPD) who uses
oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the
client is
having increased shortness of breath with respirations at 23 breaths/minute. Which
action
should the nurse implement first?
a. Determine if the client is experiencing any anxiety.
b. Auscultate the client's bilateral lung sounds and oxygen saturation.
c. Notify the healthcare provider about the client's distress.
d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula. -
ANS... -d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
Which statement by a client who is 24 hours post-subtotal thyroidectomy requires
an
immediate investigation by the nurse?
a. "When I get out of bed quickly, I feel a little dizzy."
b. "The dressing over my incision feels like it is too tight."
c. "I'm most comfortable when the head of the bed is raised."
d. "This IV infusion makes me urinate more often than usual. - ANS... -a. "When I
get out of bed quickly, I feel a little dizzy."
An older adult male who is in his early 70's is admitted to the emergency
department because of
a COPD exacerbation. This client is struggling to breathe and the healthcare team
is preparing
, for endotracheal intubation. The spouse's wife, who is 30 years younger than the
client, asks the
nurse to stop the procedure and provide the nurse a copy of the client's living will.
Which action
should the nurse take?
a. Facilitate a family meeting with the palliative care team.
b. Notify the healthcare provider of the client's wishes.
c. Place a certified copy of the living will in the client's record.
d. Alert the nursing staff of the client's don't resuscitate status. - ANS... -b. Notify
the healthcare provider of the client's wishes.
An unlicensed assistive personnel (UAP) is assigned to provide personal care for a
client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the
nurse that the
client is so obese that the UAP feels unable to safely assist the client in transferring
from the bed
to the bedside commode. How should the nurse respond?
a. Determine the client's level of mobility and need for assistance.
b. Instruct the UAP that all clients deserve equal care.
c. Advice the client to maintain bedrest so that safety can be ensured.
d. Assign another UAP to care for the client - ANS... -c. Advice the client to
maintain bedrest so that safety can be ensured.
A nurse determines that more than 25% of the students at a middle school are
overweight. The
nurse presents the information at the parent-teacher meeting. What action is most
important
for the nurse to include in the meeting?
a. Provide information on ways to increase activity for the family.
b. Have several teachers talk about health risks associated with obesity.
c. Distribute a shopping list of suggested healthy snack items.
d. Determine the parents' degree of concern about their children's weight. - ANS...
-c. Distribute a shopping list of suggested healthy snack items.
After several months of chronic fatigue, morning stiffness, and join pain, a young
adult is
diagnosed with rheumatoid arthritis, and the healthcare provider prescribes
prednisone. Which
education should the nurse provide the client with regard to taking prednisone?
LATEST UPDATE ASSURED PASS
A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer's solution at 75
mL/hour IV. One
hour after admission to the unit, the nurse notes 300 mL of blood in the suction
canister, the
client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In
addition to
reporting the finding to the surgeon. Which action should the nurse implement
first?
a. Measure and document the client's urinary output.
b. Request the client's reserved unit if packed red blood cells.
c. Prepare the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer's solution - ANS... -d. Increase the
infusion rate of Lactated Ringer's solution
an adult male who fell 20 feet from the roof of this home has multiple injuries,
including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his
transfer to
the intensive care unit (ICU). the nurse notes that the suction control chamber is
bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml
of bright red
blood is measured in the collection chamber. Which intervention should the nurse
implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as autotransfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in water seal - ANS... -a. Add
sterile water to the suction control chamber.
A client who received hemodialysis yesterday is experiencing a blood pressure of
200/100
,mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The
client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation
on room air
of 89%. Which action should the nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client's fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis. - ANS... -c. Begin supplemental oxygen.
A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation.
Based on the client's admitting diagnosis, which findings require immediate action
by the nurse?
(Select all that apply)
a. Headache and tremors
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis - ANS... -a. Headache and tremors
An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding
is the best indicator of hydration that the nurse should report to the healthcare
provider?
a. Urine specific gravity is 1.040
b. Systolic blood pressure decreases 10 points when standing.
c. The client denies being thirsty.
d. Skin tenting occurs when the client's forearm is pinched. - ANS... -d. Skin
tenting occurs when the client's forearm is pinched.
After an inservice about electronic health record (EHR) security and safeguarding
client
information, the nurse observes a colleague going home with printed copies of
client
information in a uniform pocket. Which action should the nurse take?
a. File a detailed incident report with the specific hiring facility.
b. Warn the colleague that their actions are unprofessional.
c. Comment anonymously about the action of a staff discussion board.
,d. Communicate the colleague's actions to the unit charge nurse - ANS... -a. File a
detailed incident report with the specific hiring facility.
The nurse is evaluating a tertiary prevention program for clients with
cardiovascular disease
implemented in a rural health clinic. Which outcome indicate the program is
effective?
a. At-risk clients received an increased number of routine health screenings.
b. Clients reported having new confidence in making healthy food choices.
c. Clients who incurred disease complications promptly received rehabilitation.
d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
- ANS... -c. Clients who incurred disease complications promptly received
rehabilitation.
The nurse is caring for a client with chronic obstructive pulmonary disease
(COPD) who uses
oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the
client is
having increased shortness of breath with respirations at 23 breaths/minute. Which
action
should the nurse implement first?
a. Determine if the client is experiencing any anxiety.
b. Auscultate the client's bilateral lung sounds and oxygen saturation.
c. Notify the healthcare provider about the client's distress.
d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula. -
ANS... -d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
Which statement by a client who is 24 hours post-subtotal thyroidectomy requires
an
immediate investigation by the nurse?
a. "When I get out of bed quickly, I feel a little dizzy."
b. "The dressing over my incision feels like it is too tight."
c. "I'm most comfortable when the head of the bed is raised."
d. "This IV infusion makes me urinate more often than usual. - ANS... -a. "When I
get out of bed quickly, I feel a little dizzy."
An older adult male who is in his early 70's is admitted to the emergency
department because of
a COPD exacerbation. This client is struggling to breathe and the healthcare team
is preparing
, for endotracheal intubation. The spouse's wife, who is 30 years younger than the
client, asks the
nurse to stop the procedure and provide the nurse a copy of the client's living will.
Which action
should the nurse take?
a. Facilitate a family meeting with the palliative care team.
b. Notify the healthcare provider of the client's wishes.
c. Place a certified copy of the living will in the client's record.
d. Alert the nursing staff of the client's don't resuscitate status. - ANS... -b. Notify
the healthcare provider of the client's wishes.
An unlicensed assistive personnel (UAP) is assigned to provide personal care for a
client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the
nurse that the
client is so obese that the UAP feels unable to safely assist the client in transferring
from the bed
to the bedside commode. How should the nurse respond?
a. Determine the client's level of mobility and need for assistance.
b. Instruct the UAP that all clients deserve equal care.
c. Advice the client to maintain bedrest so that safety can be ensured.
d. Assign another UAP to care for the client - ANS... -c. Advice the client to
maintain bedrest so that safety can be ensured.
A nurse determines that more than 25% of the students at a middle school are
overweight. The
nurse presents the information at the parent-teacher meeting. What action is most
important
for the nurse to include in the meeting?
a. Provide information on ways to increase activity for the family.
b. Have several teachers talk about health risks associated with obesity.
c. Distribute a shopping list of suggested healthy snack items.
d. Determine the parents' degree of concern about their children's weight. - ANS...
-c. Distribute a shopping list of suggested healthy snack items.
After several months of chronic fatigue, morning stiffness, and join pain, a young
adult is
diagnosed with rheumatoid arthritis, and the healthcare provider prescribes
prednisone. Which
education should the nurse provide the client with regard to taking prednisone?
