HESI_EXIT-7(39) Latest Question & Answers (A
grade)
271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at
bedtime. What action should the nurse take?
{{{Answer}}} (Administer the medication as prescribed with a glass of water)
272. Which client should the nurse assess frequently because of the risk for overflow
incontinence? A client
{{{Answer}}} (Who is confused and frequently forgets to go to the bathroom)
273. While monitoring a client during a seizure, which interventions should the nurse
implement? (Select all that apply)
{{{Answer}}} (Move obstacle away from client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure)
274. A male client with a long history of alcoholism is admitted because of mild
confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped
smoking cigarettes one month ago after his brother died of lung cancer. Which
intervention is most important for the nurses to include in the client's plan of care?
{{{Answer}}} (Observe for changes in level of consciousness.)
275. An older adult female admitted to the intensive care unit (ICU) with a possible
stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory
rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH
7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG
finding, which action is required?
{{{Answer}}} (Increase ventilator rate.)
276. The mother of the 12- month-old with cystic fibrosis reports that her child is
experiencing increasing congestion despite the use of chest physical therapy (CPT)
twice a day, and has also experiences a loss of appetite. What instruction should the
nurse provide?
{{{Answer}}} (CPT should be performed more frequently, but at least an hour before
meals.)
277. The nurse is evaluating the diet teaching of a client with hypertension. What dinner
selection indicates that the client understands the dietary recommendation for
hypertension?
{{{Answer}}} (Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie)
,278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic
episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units
subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are
prescribed. What action should the nurse include in this client's plan of care?
{{{Answer}}} (Fingerstick glucose assessment q6h with meals
Review with the client proper foot care and prevention of injury
Coordinate carbohydrate controlled meals at consistent times and intervals
Teach subcutaneous injection technique, site rotation and insulin management)
279. Which problem reported by a client taking lovastatin requires the most immediate
fallow up by the nurse?
{{{Answer}}} (Muscle pain)
280. While assessing a client's chest tube (CT), the nurse discovers bubbling in the
water seal chamber of the chest tube collection device. The client's vital signs are: blood
pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32
breaths/minutes, oxygen saturation 88%. Which interventions should the nurse
implement?
{{{Answer}}} (Provide supplemental oxygen
Auscultate bilateral lung fields
Reinforce occlusive CT dressing)
281. Before leaving the room of a confused client, the nurse notes that a half bow knot
was used to attach the client's wrist restraints to the movable portion of the client's bed
frame. What action should the nurse take before leaving the room?
{{{Answer}}} (Ensure that the knot can be quickly released.)
282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media.
An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What
instruction should the nurse emphasize concerning the installation of the
antipyrine/benzocaine otic solution?
{{{Answer}}} (Have the child lie with the ear up for one to two minute after installation.)
283. An older adult male is admitted with complications related to chronic obstructive
pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion
and his weakness has increased over the past month. The nurse notes that he has
dependent edema in both lower legs. Based on these assessment findings, which
dietary instruction should the nurse provide?
{{{Answer}}} (Restrict daily fluid intake.)
284. The nurse inserts an indwelling urinary catheter as seen in the video what action
should the nurse take next?
{{{Answer}}} (Leave the catheter in place and obtain a sterile catheter.)
285. A client with coronary artery disease who is experiencing syncopal episodes is
admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy.
,Which intervention should the nurse delegate to the unlicensed assistive personnel
(UAP)?
{{{Answer}}} (Prepare the skin for procedure.)
286. Fallowing an outbreak of measles involving 5 students in an elementary school,
which action is most important for the school nurse to take?
{{{Answer}}} (Restrict unvaccinated children from attending school until measles
outbreak is resolved.)
287. A preeclamptic client who delivered 24h ago remains in the labor and delivery
recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her
total input is limited to 125 ml per hour, and her urinary output for the last hour was 850
ml. What intervention should the nurse implement?
{{{Answer}}} (Continue with the plan of care for this client)
288. The nurse is planning care for a client who admits having suicidal thoughts. Which
client behavior indicates the highest risk for the client acting on these suicidal thoughts?
{{{Answer}}} (Begin to show signs of improvement in affect)
289. When assessing a multigravida the first postpartum day, the nurse finds a
moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above
the umbilicus. What action should the nurse implement first?
{{{Answer}}} (Check for a destined bladder)
290. A 12 year old client who had an appendectomy two days ago is receiving 0.9%
normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action
should the nurse implement?
{{{Answer}}} (Encourage popsicles and fluids of choice)
291. An older male client arrives at the clinic complaining that his bladder always feels
full. He complains of weak urine flow, frequent dribbling after voiding, and increasing
nocturia with difficulty initiating his urine stream. Which action should the nurse
implement?
{{{Answer}}} (Palpate the client's suprapubic area for distention)
292. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old
infant. Which action should the nurse include?
{{{Answer}}} (Divide the medication into two injection with volumes under 1ml)
293. A client who had a below the knee amputation is experiencing severe phantom
limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which
response by the nurse is likely to be most helpful?
{{{Answer}}} (Research indicates that mirror therapy is effective in reducing phantom
limb pain)
, 294. An older adult client with heart failure (HF) develops cardiac tamponade. The client
has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen
therapy and IV hydration, which intervention is most important for the nurse to
implement?
{{{Answer}}} (Notify healthcare provider to prepare for pericardiocentesis)
295. A new member joins the nursing team spreads books on the table, puts items on
two chairs, and sits on a third chair. The members of the group are forced to move
closer and remove their possessions from the table what action should the nurse leader
take?
{{{Answer}}} (Ask the new person to move belonging to accommodate others)
296. The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP)
shunt that was placed 2 days after birth. Which findings are an indication of a
postoperative complication?
{{{Answer}}} (Poor feeding and vomiting
Leakage of CSF from the incisional site
Abdominal distention)
297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs
220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with
the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse
administer? (Enter numeric value only)
{{{Answer}}} (8)
298. In monitoring tissue perfusion in a client following an above the knee amputation
(aka), which action should the nurse include in the plan of care?
{{{Answer}}} (Evaluate closet proximal pulse.)
299. The leg of a client who is receiving hospice care have become mottled in
appearance. When the nurse observes the unlicensed assistive personal (UAP) place a
heating pad on the mottled areas, what action should the nurse take?
{{{Answer}}} (Remove the heating pads and place a soft blanket over the client's leg and
feet.)
300. A client who underwent an uncomplicated gastric bypass surgery is having difficult
with diet management. What dietary instruction is most important for the nurse to
explain to the client?
{{{Answer}}} (Plan volume-controlled evenly-space meal thorough the day)
301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous
membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child
has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to
this finding?
{{{Answer}}} (Insensible loss of body fluids contributes to the hemoconcentration of
serum solutes)
grade)
271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at
bedtime. What action should the nurse take?
{{{Answer}}} (Administer the medication as prescribed with a glass of water)
272. Which client should the nurse assess frequently because of the risk for overflow
incontinence? A client
{{{Answer}}} (Who is confused and frequently forgets to go to the bathroom)
273. While monitoring a client during a seizure, which interventions should the nurse
implement? (Select all that apply)
{{{Answer}}} (Move obstacle away from client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure)
274. A male client with a long history of alcoholism is admitted because of mild
confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped
smoking cigarettes one month ago after his brother died of lung cancer. Which
intervention is most important for the nurses to include in the client's plan of care?
{{{Answer}}} (Observe for changes in level of consciousness.)
275. An older adult female admitted to the intensive care unit (ICU) with a possible
stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory
rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH
7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG
finding, which action is required?
{{{Answer}}} (Increase ventilator rate.)
276. The mother of the 12- month-old with cystic fibrosis reports that her child is
experiencing increasing congestion despite the use of chest physical therapy (CPT)
twice a day, and has also experiences a loss of appetite. What instruction should the
nurse provide?
{{{Answer}}} (CPT should be performed more frequently, but at least an hour before
meals.)
277. The nurse is evaluating the diet teaching of a client with hypertension. What dinner
selection indicates that the client understands the dietary recommendation for
hypertension?
{{{Answer}}} (Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie)
,278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic
episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units
subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are
prescribed. What action should the nurse include in this client's plan of care?
{{{Answer}}} (Fingerstick glucose assessment q6h with meals
Review with the client proper foot care and prevention of injury
Coordinate carbohydrate controlled meals at consistent times and intervals
Teach subcutaneous injection technique, site rotation and insulin management)
279. Which problem reported by a client taking lovastatin requires the most immediate
fallow up by the nurse?
{{{Answer}}} (Muscle pain)
280. While assessing a client's chest tube (CT), the nurse discovers bubbling in the
water seal chamber of the chest tube collection device. The client's vital signs are: blood
pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32
breaths/minutes, oxygen saturation 88%. Which interventions should the nurse
implement?
{{{Answer}}} (Provide supplemental oxygen
Auscultate bilateral lung fields
Reinforce occlusive CT dressing)
281. Before leaving the room of a confused client, the nurse notes that a half bow knot
was used to attach the client's wrist restraints to the movable portion of the client's bed
frame. What action should the nurse take before leaving the room?
{{{Answer}}} (Ensure that the knot can be quickly released.)
282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media.
An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What
instruction should the nurse emphasize concerning the installation of the
antipyrine/benzocaine otic solution?
{{{Answer}}} (Have the child lie with the ear up for one to two minute after installation.)
283. An older adult male is admitted with complications related to chronic obstructive
pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion
and his weakness has increased over the past month. The nurse notes that he has
dependent edema in both lower legs. Based on these assessment findings, which
dietary instruction should the nurse provide?
{{{Answer}}} (Restrict daily fluid intake.)
284. The nurse inserts an indwelling urinary catheter as seen in the video what action
should the nurse take next?
{{{Answer}}} (Leave the catheter in place and obtain a sterile catheter.)
285. A client with coronary artery disease who is experiencing syncopal episodes is
admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy.
,Which intervention should the nurse delegate to the unlicensed assistive personnel
(UAP)?
{{{Answer}}} (Prepare the skin for procedure.)
286. Fallowing an outbreak of measles involving 5 students in an elementary school,
which action is most important for the school nurse to take?
{{{Answer}}} (Restrict unvaccinated children from attending school until measles
outbreak is resolved.)
287. A preeclamptic client who delivered 24h ago remains in the labor and delivery
recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her
total input is limited to 125 ml per hour, and her urinary output for the last hour was 850
ml. What intervention should the nurse implement?
{{{Answer}}} (Continue with the plan of care for this client)
288. The nurse is planning care for a client who admits having suicidal thoughts. Which
client behavior indicates the highest risk for the client acting on these suicidal thoughts?
{{{Answer}}} (Begin to show signs of improvement in affect)
289. When assessing a multigravida the first postpartum day, the nurse finds a
moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above
the umbilicus. What action should the nurse implement first?
{{{Answer}}} (Check for a destined bladder)
290. A 12 year old client who had an appendectomy two days ago is receiving 0.9%
normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action
should the nurse implement?
{{{Answer}}} (Encourage popsicles and fluids of choice)
291. An older male client arrives at the clinic complaining that his bladder always feels
full. He complains of weak urine flow, frequent dribbling after voiding, and increasing
nocturia with difficulty initiating his urine stream. Which action should the nurse
implement?
{{{Answer}}} (Palpate the client's suprapubic area for distention)
292. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old
infant. Which action should the nurse include?
{{{Answer}}} (Divide the medication into two injection with volumes under 1ml)
293. A client who had a below the knee amputation is experiencing severe phantom
limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which
response by the nurse is likely to be most helpful?
{{{Answer}}} (Research indicates that mirror therapy is effective in reducing phantom
limb pain)
, 294. An older adult client with heart failure (HF) develops cardiac tamponade. The client
has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen
therapy and IV hydration, which intervention is most important for the nurse to
implement?
{{{Answer}}} (Notify healthcare provider to prepare for pericardiocentesis)
295. A new member joins the nursing team spreads books on the table, puts items on
two chairs, and sits on a third chair. The members of the group are forced to move
closer and remove their possessions from the table what action should the nurse leader
take?
{{{Answer}}} (Ask the new person to move belonging to accommodate others)
296. The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP)
shunt that was placed 2 days after birth. Which findings are an indication of a
postoperative complication?
{{{Answer}}} (Poor feeding and vomiting
Leakage of CSF from the incisional site
Abdominal distention)
297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs
220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with
the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse
administer? (Enter numeric value only)
{{{Answer}}} (8)
298. In monitoring tissue perfusion in a client following an above the knee amputation
(aka), which action should the nurse include in the plan of care?
{{{Answer}}} (Evaluate closet proximal pulse.)
299. The leg of a client who is receiving hospice care have become mottled in
appearance. When the nurse observes the unlicensed assistive personal (UAP) place a
heating pad on the mottled areas, what action should the nurse take?
{{{Answer}}} (Remove the heating pads and place a soft blanket over the client's leg and
feet.)
300. A client who underwent an uncomplicated gastric bypass surgery is having difficult
with diet management. What dietary instruction is most important for the nurse to
explain to the client?
{{{Answer}}} (Plan volume-controlled evenly-space meal thorough the day)
301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous
membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child
has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to
this finding?
{{{Answer}}} (Insensible loss of body fluids contributes to the hemoconcentration of
serum solutes)
