HESI RN FUNDAMENTALS EXIT EXAM | Questions and answers | 2022

24.While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth. C) Reinforce the need to grip directly under the joint for better support. D) Instruct her to grip directly over the joint for better motion. 25.A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A) Sexual activity patterns. B) Nutritional history. C) Leisure activities. D) Financial stressors 26.The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr D) Obtain a stat blood glucose level and notify the healthcare provider. 27.A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A) Administer the medication more rapidly using the same IV site. B) Initiate an alternate site for the IV infusion of the medication. C) Notify the healthcare provider before administering the next dose. D) Give the client a PRN dose of aspirin while the medication infuses 28.The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A) Genetic and familial health disorders. B) Chronic health problems. C) Reason for seeking health care. D) Undetected disorders. 29.Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A) 11,000 units. B) 13,000 units. C) 15,000 units. D) 17,000 units 30. A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A) demonstrates loss of remote memory. B) exhibits expressive dysphasia. C) has a diminished attention span. D) is disoriented to place and time. 31. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client’s oxygen saturation level is 92%. What intervention should the nurse implement? A) Decrease the flow rate to 1 L/minute. B) Discontinue the use of the nasal cannula. C) Apply lubricant to the cannula tubing. D) Place padding around the cannula tubing. 32. A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, what intervention is most important for the nurse to implement? A) Ask a Spanish speaking staff member to talk with the family. B) Use a Spanish translation reference to interview the family. C) Close the door to client’s room to provide family privacy. D) Sit quietly with the family to offer comfort and support. 33. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. The wound has a gauze dressing covering the area. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing B) Increase the frequency of the dressing changes. C) Replace the gauze with transparent dressing. D) Leave the dressing off until consulting with the healthcare provider. 34. The healthcare provider prescribes haloperidol (Haldol) 1.5mg twice daily for a client with Tourette’s syndrome. The drug is available in a solution labeled, “2 mg/ml.” How many ml should the nurse administer? (Round to the nearest hundredth.) 0.75