EXIT HESI
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he
will
drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is
the
best follow-up action by the nurse? - Review with the client the need to avoid foods that
are rich in milk and cream
A male client with hypertension, who received new antihypertensive prescriptions at his
last
visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is
158/106 and he admits that he has not been taking the prescribed medication because
the
drugs make him "feel bad". In explaining the need for hypertension control, the nurse
should
stress that an elevated BP places the client at risk for which pathophysiological
condition? - Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted
client who has a seizure disorder. The client is supine and the UAP is placing soft
pillows
along the side rails. What action should the nurse implement? - Instruct the UAP to
obtain soft blankets to secure to the side rails instead of pillows.
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the
past 12 days. Which assessment finding requires immediate follow-up? - Describes life
without purpose
A 60-year-old female client with a positive family history of ovarian cancer has
developed an
abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau
(Pap)
smear results are negative. What information should the nurse include in the client's
teaching
plan? - Further evaluation involving surgery may be needed
A client who recently underwear a tracheostomy is being prepared for discharge to
home.
Which instructions is most important for the nurse to include in the discharge plan? -
Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen
reservoir bag does not deflate completely during inspiration and the client's respiratory
rate is
,EXIT HESI
14 breaths / minute. What action should the nurse implement? - Document the
assessment data — Rational: reservoir bag should not deflate
completely during inspiration and the client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms.
Which
client alarm should the nurse investigate firs? - Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What
action should the nurse take first? - Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section),
the
client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid
getting a headache. Which action should the nurse take first? - Inform the anesthesia
care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart
sounds. To determine if an S3 heart sound is present, what action should the nurse take
first? - Listen with the bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance through her
place
of employment. Which agency should the client be referred to by the employee health
nurse
for health insurance needs? - Medicare
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset.
What
snack should the nurse instruct the client to take with the tetracycline? - Toasted wheat
bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint
indicated to
the nurse that the client is experiencing a complication? - "I have a headache that gets
worse when I sit up"
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency
with
incontinence. Which action should the nurse implement? - Obtain a clean catch mid-
stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods
that
,EXIT HESI
are in keeping with the child's dietary restrictions. Which foods are contraindicated for
this
child? - Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse
asks the
circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client.
Which response should the circulating nurse provide? - Direct the nurse to continue the
surgical hand scrub for a 5 minute duration
Which breakfast selection indicates that the client understands the nurse's instructions
about
the dietary management of osteoporosis? - Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less
than
the optimal number of registered nurses will be working that shift. In planning
assignments,
which client should receive the most care hours by a registered nurse (RN)? - An 82-
year-old client with Alzheimer's disease newly-fractures femur who has a
Foley catheter and soft wrist restrains applied
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the
pediatrician's office. Upon inspection, the nurse notes that the nail went through the
shoe and
pierced the bottom of the child's foot. Which action should the nurse implement first? -
Cleanse the foot with soap and water and apply an antibiotic ointment
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have
been
applying triple antibiotic ointment for two days, but there has been no improvement."
What
instruction should the nurse provide? - Stop using the ointment and encourage
complete drying of the feet and wearing
clean socks.
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter,
and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse
that
the prescribed dosage is too high for this client? The client experiences - Palpitations
and shortness of breath
A client with a history of heart failure presents to the clinic with a nausea, vomiting,
yellow
, EXIT HESI
vision and palpitations. Which finding is most important for the nurse to assess to the
client? - Obtain a list of medications taken for cardiac history
The pathophysiological mechanism are responsible for ascites related to liver failure?
(Select
all that apply) - - Fluid shifts from intravascular to interstitial area due to decreased
serum protein
- Increased hydrostatic pressure in portal circulation increases fluid shifts into
abdomen
- Increased circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the nurse
use to
document this sound? (Please listen to the audio first to select the option that applies) -
Murmur — Rationale: A murmur is auscultated as a swishing sound that is associated
with the blood turbulence created by the heart or valvular defect.
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six
hours
for four days. What assessment is most important for the nurse to complete? -
Auscultate the client's bowel sounds
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and
frequently
causes constipation, so it is most important to Auscultate the client's bowel sounds
A female client is admitted with end stage pulmonary disease is alert, oriented, and
complaining of shortness of breath. The client tells the nurse that she wants "no heroic
measures" taken if she stops breathing, and she asks the nurse to document this in her
medical record. What action should the nurse implement? - Ask the client to discuss "do
not resuscitate" with her healthcare provider
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and
has
developed diarrhea. The client has a new prescription to change the feeding to half
strength.
What intervention should the nurse implement? - Add equal amounts of water and
feeding to a feeding bag and infuse at 50ml/hour
A female client reports that her hair is becoming coarse and breaking off, that the outer
part
of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up
question
is best for the nurse to ask? - Have you noticed any changes in your fingernails? —
Rationale: The pattern of
reported manifestations is suggestive of hypothyroidism
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he
will
drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is
the
best follow-up action by the nurse? - Review with the client the need to avoid foods that
are rich in milk and cream
A male client with hypertension, who received new antihypertensive prescriptions at his
last
visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is
158/106 and he admits that he has not been taking the prescribed medication because
the
drugs make him "feel bad". In explaining the need for hypertension control, the nurse
should
stress that an elevated BP places the client at risk for which pathophysiological
condition? - Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted
client who has a seizure disorder. The client is supine and the UAP is placing soft
pillows
along the side rails. What action should the nurse implement? - Instruct the UAP to
obtain soft blankets to secure to the side rails instead of pillows.
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the
past 12 days. Which assessment finding requires immediate follow-up? - Describes life
without purpose
A 60-year-old female client with a positive family history of ovarian cancer has
developed an
abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau
(Pap)
smear results are negative. What information should the nurse include in the client's
teaching
plan? - Further evaluation involving surgery may be needed
A client who recently underwear a tracheostomy is being prepared for discharge to
home.
Which instructions is most important for the nurse to include in the discharge plan? -
Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen
reservoir bag does not deflate completely during inspiration and the client's respiratory
rate is
,EXIT HESI
14 breaths / minute. What action should the nurse implement? - Document the
assessment data — Rational: reservoir bag should not deflate
completely during inspiration and the client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms.
Which
client alarm should the nurse investigate firs? - Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What
action should the nurse take first? - Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section),
the
client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid
getting a headache. Which action should the nurse take first? - Inform the anesthesia
care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart
sounds. To determine if an S3 heart sound is present, what action should the nurse take
first? - Listen with the bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance through her
place
of employment. Which agency should the client be referred to by the employee health
nurse
for health insurance needs? - Medicare
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset.
What
snack should the nurse instruct the client to take with the tetracycline? - Toasted wheat
bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint
indicated to
the nurse that the client is experiencing a complication? - "I have a headache that gets
worse when I sit up"
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency
with
incontinence. Which action should the nurse implement? - Obtain a clean catch mid-
stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods
that
,EXIT HESI
are in keeping with the child's dietary restrictions. Which foods are contraindicated for
this
child? - Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse
asks the
circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client.
Which response should the circulating nurse provide? - Direct the nurse to continue the
surgical hand scrub for a 5 minute duration
Which breakfast selection indicates that the client understands the nurse's instructions
about
the dietary management of osteoporosis? - Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less
than
the optimal number of registered nurses will be working that shift. In planning
assignments,
which client should receive the most care hours by a registered nurse (RN)? - An 82-
year-old client with Alzheimer's disease newly-fractures femur who has a
Foley catheter and soft wrist restrains applied
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the
pediatrician's office. Upon inspection, the nurse notes that the nail went through the
shoe and
pierced the bottom of the child's foot. Which action should the nurse implement first? -
Cleanse the foot with soap and water and apply an antibiotic ointment
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have
been
applying triple antibiotic ointment for two days, but there has been no improvement."
What
instruction should the nurse provide? - Stop using the ointment and encourage
complete drying of the feet and wearing
clean socks.
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter,
and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse
that
the prescribed dosage is too high for this client? The client experiences - Palpitations
and shortness of breath
A client with a history of heart failure presents to the clinic with a nausea, vomiting,
yellow
, EXIT HESI
vision and palpitations. Which finding is most important for the nurse to assess to the
client? - Obtain a list of medications taken for cardiac history
The pathophysiological mechanism are responsible for ascites related to liver failure?
(Select
all that apply) - - Fluid shifts from intravascular to interstitial area due to decreased
serum protein
- Increased hydrostatic pressure in portal circulation increases fluid shifts into
abdomen
- Increased circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the nurse
use to
document this sound? (Please listen to the audio first to select the option that applies) -
Murmur — Rationale: A murmur is auscultated as a swishing sound that is associated
with the blood turbulence created by the heart or valvular defect.
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six
hours
for four days. What assessment is most important for the nurse to complete? -
Auscultate the client's bowel sounds
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and
frequently
causes constipation, so it is most important to Auscultate the client's bowel sounds
A female client is admitted with end stage pulmonary disease is alert, oriented, and
complaining of shortness of breath. The client tells the nurse that she wants "no heroic
measures" taken if she stops breathing, and she asks the nurse to document this in her
medical record. What action should the nurse implement? - Ask the client to discuss "do
not resuscitate" with her healthcare provider
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and
has
developed diarrhea. The client has a new prescription to change the feeding to half
strength.
What intervention should the nurse implement? - Add equal amounts of water and
feeding to a feeding bag and infuse at 50ml/hour
A female client reports that her hair is becoming coarse and breaking off, that the outer
part
of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up
question
is best for the nurse to ask? - Have you noticed any changes in your fingernails? —
Rationale: The pattern of
reported manifestations is suggestive of hypothyroidism
