2020 HESI EXIT V2-Elaborated Responses

1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa." D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." The correct answer is D: "I have the four year-old hold and help feed the four month-old a bottle in the kitchen 2. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary The correct answer is B: Give information about advance directives 3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered The correct answer is B: Administer epinephrine 1:1000 as ordered . 4. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? A) An infant with intermittent bulging anterior fontanel between crying episodes B) A toddler with severe deep abrasions over 98% of the body C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture D) A school-age child with singed eyebrows and hair on the arms The correct answer is B: A toddler with severe deep abrasions over 98% of the bodyhesiexitv2examlatestmaternityelaboratedlatest 2021