2013 HESI V6 ALL ANSWERS GUARANTEE GRADE ‘A’ 100%

1. A male client who had a transurethral resection of the prostate (TURP) today has a continuous bladder irrigation (CBI). The client requests pain medication for abdominal pain rated at “9“ on a scale of 1 to 10. What action should the nurse take first? A. Administer prescribed PRN analgesic medication. B. Position him on the left side and slow the irrigation rate. C. Palpate his abdomen and check his urinary output. D. Assist him to ambulate to help pass flatus. 2. The mental health nurse takes several adolescent clients to the inpatient schoolroom. The teacher asks the nurse to stay and help one of the male clients who has attention-­‐deficit hyperactivity disorder with his spelling assignment. Which goal is reasonable for this client to attain during this one-­‐ hour class? A. Completes at least one page of spelling. B. Follows directions the first time they are given. C. Sits quietly with peers and completes assignment. D. Shares his problems with others in the class. 3. A client is receiving a standardized solution of heparin 25,000-­‐units/250 ml of normal saline. The healthcare provider prescribes to increase the client’s current infusion rate of heparin to 700 units/hour. How many ml/hour should the nurse program the infusion pump? Enter the numerical value only. Using formula, D/H x Q, 700 units/hour 25,000 units x 25o ml = 7 ml/hour 4. A client is receiving the intravenous adrenergic agonist dobutamine (Dobutrex). In evaluating the client’s reaction to the medication, which assessment finding indicates to the nurse that the medication is effective? A. The client denies chest pain or discomfort. B. The client had 160 ml urine output in 8 hours. C. The client’s blood pressure is 110/70 mmHg. D. The client’s posterior tibial pulses are 1+. 5. A client misses breakfast because of a two-­‐hour hand washing ritual that is performed daily. What plan is most therapeutic for the nurse to implement? A. Meet with the client daily to discuss motivation for initiating the ritual. B. Wake the client early so the ritual can be completed before breakfast. C. Set limits on amount of time the client is allowed to perform the ritual. D. Socialize with the client during the ritual to demonstrate acceptance. 6. Which discharge instruction should the nurse provide a client with heart failure who is taking digoxin (Lanoxin)? A. Avoid concurrent use of herbal products. B. Take Lanoxin with high-­‐fiber foods. C. Restrict fluid intake to equal urine output. D. Check blood glucose level weekly. 7. The charge nurse in the Intensive Care Unit (ICU) needs to transfer a client to the medical unit so that a client from the Emergency Room can be admitted to ICU. Which client is best to consider? A. A 38-­‐year-­‐old with a myocardial infarction who is having multifocal premature ventricular contractions. B. A 66-­‐year-­‐old with congestive heart failure who has 2+ pitting edema and is short of breath on exertion. C. A 58-­‐year-­‐old diagnosed with Guillain-­‐Barre syndrome who is having difficulty breathing. D. An 80-­‐year-­‐old with a bleeding peptic ulcer who has a Hgb of 7 g/dl and coffee ground drainage from NG. 8. The nurse stops to render aid at the scene of a motor vehicle collision and finds a child about 6 months of age strapped into a car seat in the back seat of the car. After calming the infant with a pacifier, what action should the nurse take? A. Remove the infant from the car seat while stabilizing the neck. B. Assess the infant’s ability to move arms and legs. C. Determine if pupils constrict when exposed to light. D. Lift the car seat out of the car with the infant strapped in it. 9. An unresponsive female victim of a motor vehicle collision is brought to the emergency department where it is determined that immediate surgery is required to save her life. The client is accompanied by a close friend, but no family members are available. Which intervention should the nurse implement? A. Obtain an emergency court order for life-­‐saving surgery for the client. B. Prepare the client for surgery without a signed informed consent. C. Ask the woman’s friend if the client has an advanced directive. D. Monitor the client until a family member can be located. 10. A confused and combative male client was placed in bilateral wrist restraints to keep him from pulling out a nasogastric tube. The client developed severe abrasions on both wrists. On the morning that the abrasions were found, the client’s record contained nursing documentation stating that skin and circulation checks were conducted every 6 to 8 hours. How should the nurse-­‐ manager respond to this situation? A. Meet with the client’s nurse to determine why adequate assessment was not performed. B. Reassure the staff that skin damage can occur even when the standard of care is met. C. Provide an in-­‐service on the documentation needed for clients with altered skin integrity. D. Instruct the staff about the correct protocol for the application of bilateral wrist restraints. 11. When the nurse auscultates the anterior chest just above the right nipple, moderate pitched breath sounds are heard that are equal on inspiration and expiration. Which statement best describes this finding? A. Bronchial breath sounds that are normal in that location. B. Bronchovesicular breath sounds that are abnormal in that location. C. Bronchial breath sounds that are abnormal in that location. D. Bronchovesicular breath sounds that are normal in that location. 12. A client is seen in the clinic with an acute episode of acute gastritis. Which nursing diagnosis has the highest priority? A. Acute pain related to inflammation. B. Nausea related to gastric irritation. C. Knowledge deficit related to diet. D. Potential for injury related to bleeding. 13. The nurse should encourage males over the age of 45 to obtain which test to screen for prostatic cancer? A. Prostate-­‐specific antigen (PSA). B. Serum testosterone level. C. Alpha-­‐fetoprotein radioimmunoassay (AFP). D. Ultrasound of the scrotum. 14. A male client tells the nurse that he does not want to receive a blood transfusion that was prescribed to treat internal hemorrhaging. What action should the nurse implement? A. Notify the prescribing healthcare provider of the client’s refusal to receive the blood transfusion. B. Notify the hospital’s attorney of the client’s wishes and the need to exercise life-­‐saving measures. C. Check the client’s medical record to see if he signed a legal informed consent form. D. Explain the treatment options available to him if he refuses the prescribed blood transfusion. 15. The nurse is caring for a laboring client whose membranes ruptured 24 hours prior to admission. Based on the laboring client’s record and the current fetal monitor reading, which action should the nurse implement? (Click on each chart for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.) A. Stop the oxytocin infusion. B. Prepare for Cesarean delivery. C. Assess the vital signs. D. Apply oxygen 10 L/mask. 16. Which nursing intervention has the highest priority when completing discharge teaching for a client with Helicobacter pylori (H. pylori) induced peptic ulcer diseases (PUD)? A. Refer the client to a counselor for information on stress reduction and relaxation. B. Encourage the client to eat regularly scheduled meals to help prevent the pain. C. Instruct the client to take all the antibiotics, proton pump inhibitors, and Pepto-­‐Bismol. D. Teach the importance of taking the Carafate medication immediately before meals. 17. A client had a total hip replacement two days ago. She has never been in the hospital before. She has just called for the bedpan. How should the nurse place the pan under this client? A. Ask her to roll to the unoperated side and slide the bedpan under her, then roll back onto the pan. B. Ask her to roll to the operated side and slide the bedpan under her, then roll her back onto the pan. C. Ask her to flex her knees, spread her legs, and lift her buttocks with the flat part of her feet, then push the bedpan under her from the front. D. Ask her to grab her over bed trapeze, push both heels into the mattress, and raise her buttocks off the bed so the bedpan can be slipped under her. 18. A male client diagnosed with hypertension has a nursing goal of, “The client will be able to verbalize ways to decrease blood pressure.” What statement by the client indicates that this outcome has been met? A. “I should have my blood pressure checked monthly to make sure it is within normal limits.” B. “If I lose weight, quit smoking, and exercise regularly I may not have to take any medication.” C. “I should increase my fluid intake and decrease my fiber intake.” D. “If I take my medication every day, I won’t have to worry about my blood pressure.” 19. On the third day of hospitalization for depression, a male client tells the nurse that he is feeling much better and reports that he believes the antidepressant therapy is working. He participates in all scheduled activities and agrees to take on additional ward assignments. What nursing action is most important for the nurse to implement at this time? A. Assign an attendant to monitor the client’s whereabouts at all times. B. Praise the client’s willingness to take on additional duties. C. Encourage the client to share his positive attitude with other clients. D. Monitor the client’s behavior and intake during meals to determine appetite. 20. A client experiencing intracranial hypertension from a traumatic brain injury is admitted to the trauma unit. How should the nurse position this client? A. Totally prone. B. Right side lying. C. Completely supine. D. Elevated head of bed. 21. The parents of a 4-­‐week-­‐old male infant report that he eats well but vomits after each feeding. Which assessment finding should the nurse expect him to exhibit if the baby is receiving inadequate nutrition? A. Tachypnea. B. Hypoactive bowel sounds.