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EXIT HESI 2022 ANSWERED ALREADY GRADED A.
An older client's daughter calls the home health nurse and reports that her mother has become
and is very confused at night. The daughter states that her mother's behavior changed suddenly
a few days a few days ago and is now getting worse. Which actions should the nurse take?
Select all that apply
a. Ask if the mother is experiencing any pain with urination.
b. Encourage increase intake of high protein foods.
c. Instruct the daughter to check her mother's temperature.
d. Review the clients current food and medication allergies.
1. The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis,
which expected outcome has the highest priority.
a. Identifies 2 treatments for Constipation due to immobility.
b. Names three home safety hazards to be resolved immediately.
c. States 4 risk factors for the development of osteoporosis.
d. List five calcium rich foods to be added to her daily diet.
1. The nurse preparing a client who had a BKA ( below the knee amp) for discharge to home.
Which recommendations should the nurse provide this client? (SATA)
a. Avoid range of motion exercises
b. Use residual limb shrinker
c. Wash the stump with soap and water
d. Inspect skin for redness
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e. Apply alcohol to the stump after bathing
A client's morning assessment includes bounding peripheral pulses, weight gain of 2lbs (0.91
kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important
for the nurse to include in this client's plan of care?
a. Restrict daily fluid intake to 1500 mL
b. Administer prescribed diuretic
c. Maintain accurate intake and output
d. Weigh client every morning
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The home care nurse visits a client who has cancer. The client reports having a good appetite
but experiencing nausea when smelling food cooking. Which action should the nurse
implement?
A. Encourage family members to cook meals outdoors and bring the cooked food inside
B. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting
C. Assess the client's mucous membranes and report the findings to the HCP
D. Advice the client to replace cooked foods with a variety of different nutritional supplements
A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted
with hyponatremia. Which intervention is most important for the nurse to include in the plan of
care to protect the client from injury?
A. administer hypertonic IV fluids as prescribed
B. Limit fluid Intake
Assess neurological status every 8 hours
Initiate seizure precautions
A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which
observation by the nurse indicates that the fistula is patent?
a. distended tortuous veins in the left hand
b. auscultation of the thrill in the left forearm
c. the left radial pulse is 2+ bounding
d. assessment of bruit on the left forearm
An older client arrives to the emergency department (ED) with reports of sever nausea and
vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature
95.4 (35.2), heart rate 112 beats/min, respirations 14 breaths/minute, and blood pressure
74/37 mmHg. Which intervention is most important for the nurse to implement?
a. Maintain Strict intake and output
b. monitor blood glucose level
EXIT HESI 2022 ANSWERED ALREADY GRADED A.
An older client's daughter calls the home health nurse and reports that her mother has become
and is very confused at night. The daughter states that her mother's behavior changed suddenly
a few days a few days ago and is now getting worse. Which actions should the nurse take?
Select all that apply
a. Ask if the mother is experiencing any pain with urination.
b. Encourage increase intake of high protein foods.
c. Instruct the daughter to check her mother's temperature.
d. Review the clients current food and medication allergies.
1. The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis,
which expected outcome has the highest priority.
a. Identifies 2 treatments for Constipation due to immobility.
b. Names three home safety hazards to be resolved immediately.
c. States 4 risk factors for the development of osteoporosis.
d. List five calcium rich foods to be added to her daily diet.
1. The nurse preparing a client who had a BKA ( below the knee amp) for discharge to home.
Which recommendations should the nurse provide this client? (SATA)
a. Avoid range of motion exercises
b. Use residual limb shrinker
c. Wash the stump with soap and water
d. Inspect skin for redness
, 1
e. Apply alcohol to the stump after bathing
A client's morning assessment includes bounding peripheral pulses, weight gain of 2lbs (0.91
kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important
for the nurse to include in this client's plan of care?
a. Restrict daily fluid intake to 1500 mL
b. Administer prescribed diuretic
c. Maintain accurate intake and output
d. Weigh client every morning
, 1
The home care nurse visits a client who has cancer. The client reports having a good appetite
but experiencing nausea when smelling food cooking. Which action should the nurse
implement?
A. Encourage family members to cook meals outdoors and bring the cooked food inside
B. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting
C. Assess the client's mucous membranes and report the findings to the HCP
D. Advice the client to replace cooked foods with a variety of different nutritional supplements
A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted
with hyponatremia. Which intervention is most important for the nurse to include in the plan of
care to protect the client from injury?
A. administer hypertonic IV fluids as prescribed
B. Limit fluid Intake
Assess neurological status every 8 hours
Initiate seizure precautions
A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which
observation by the nurse indicates that the fistula is patent?
a. distended tortuous veins in the left hand
b. auscultation of the thrill in the left forearm
c. the left radial pulse is 2+ bounding
d. assessment of bruit on the left forearm
An older client arrives to the emergency department (ED) with reports of sever nausea and
vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature
95.4 (35.2), heart rate 112 beats/min, respirations 14 breaths/minute, and blood pressure
74/37 mmHg. Which intervention is most important for the nurse to implement?
a. Maintain Strict intake and output
b. monitor blood glucose level
