Critical Care Exit Hesi Exam 2021.

Critical Care Exit Hesi Exam 2021. 27. The nurse cares for a client during a 24-hour urine specimen collection. Several hours later, the client tells the nurse that she has started to menstruate. Which action by the nurse is MOST appropriate? 1. Inform the health care provider that the client is menstruating. 2. Send the urine collected prior to the onset of the client's menstruation to the lab. 3. Insert an indwelling bladder catheter during the remainder of the collection period. 4. Request a separate urine collection container from the laboratory to be used during the remainder of the urine collection period. 28. The nurse cares for the client in the recovery room after a knee surgery procedure. The client has an oral airway in place. Which is the BEST indicator that the oral airway can be removed? 1. The client has a forceful cough during repositioning .2. The client tries to chew on the oral airway.. 3. The client tries to push the airway out with his tongue. 4. The client is able to swallow. 29. The nurse cares for clients in the antepartum clinic. Which client should the nurse see FIRST? 1. An 18-year-old multigravida client at 28 weeks gestation with a positive indirect Coombs' test. 2. A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema. 3. A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate. 4. A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of fetal movement. 30. The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix), spironolactone (Aldactone), and a low-sodium diet. Which statement by the client indicates the need for further instruction? 1. "I should weigh myself every morning and call the health care provider if I gain more than a couple of pounds in a few days." 2. "I should call the health care provider immediately if I start to feel nauseated or have difficulty breathing with normal activities." 3. "I plan to use salt substitutes now that I have to limit my sodium intake." 4. "I should read food and nonprescription medication labels to check the ingredi- ents." 11 / 11 Critical Care Exit Hesi Exam 2021 31. The nurse cares for a client scheduled for a femoral popliteal bypass proce- dure. When the nurse approaches the client with the informed consent form, the client says, "I don't need to talk to anybody about this procedure. I already know 12 / 11 Critical Care Exit Hesi Exam 2021 everything I need to know about it." Which response by the nurse is BEST? 1. "After I explain the operation to you, both of us will sign the form for legal purposes and it will be placed in your chart." 2. "Tell me what the healthcare provider told you about the risks and benefits of this operation." 3. "Can I answer any questions that you have about the procedure?" 4. "You should read all these materials to be sure that you understand everything about this procedure." 32. A man scheduled for a vasectomy tells the nurse that he and his wife are involved in a monogamous relationship. Which statement by the nurse is BEST? 1. "You will need to wear a condom when having sexual intercourse for 6 weeks following the vasectomy." 2. "No other form of birth control is necessary for you or your wife at this time." 3. "You do not need to wear a condom when having sexual intercourse for the next few weeks, but your wife should use spermicidal jelly." 4. "Always wear a condom when having sexual intercourse because not all vasec- tomies are successful." 33. The nurse prepares to assign a client requiring a capillary blood glucose test to a newly hired nursing assistive personnel. Which action should the nurse take FIRST? 1. "Show me how you check a capillary glucose level." 2. "How many of these glucose checks have you done in the past?" 3. "Would you like for me to go with you when you do the glucose test?" 4. "Was this procedure covered during your nursing assistive personnel class?" 34. A 12-year-old diagnosed boy with a fractured right femur is placed in bal- anced suspension traction with a Thomas splint and Pearson attachment. The nurse is MOST concerned by which client statement? 1. "I will experience more muscle spasms and pain while my leg is in traction." 2. "I can lift my body up while I grab the overhead trapeze and bend my left leg." 3. "The health care provider told me it is okay to move the head of my bed up and down by myself." 4. "I need to put the phone where I can reach for it without moving onto my side."