EXIT HESI 2022
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.
e. Determine if the mother has recently experienced a fall. - ✔a. Ask if the mother is
experiencing any pain with urination.
c. Instruct the daughter to check her mother's temperature.
e. Determine if the mother has recently experienced a fall.
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. - ✔b. Names three home
safety hazards to be resolved immediately.
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
e. Apply alcohol to the stump after bathing - ✔a. Inspect skin for redness
b. Use a residual limb shrinker
c. Wash the stump with soap and water
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 - ✔b. Administer prescribed diuretic
, 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. Encourage family members to cook meals outdoors and bring the
cooked food inside
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 - ✔B. Limit fluid Intake
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 - ✔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
c. keep head of bed raised 45 degrees
d. assess warmth of extremities - ✔c. keep head of bed raised 45 degrees
The home care nurse provide self-care instruction for a client chronic venous
insufficiency cause by deep vein thrombosis. Which instructions should the nurse
include in the client's discharge teaching plan? Select all that apply
a. Avoid prolonged standing or sitting
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.
e. Determine if the mother has recently experienced a fall. - ✔a. Ask if the mother is
experiencing any pain with urination.
c. Instruct the daughter to check her mother's temperature.
e. Determine if the mother has recently experienced a fall.
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. - ✔b. Names three home
safety hazards to be resolved immediately.
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
e. Apply alcohol to the stump after bathing - ✔a. Inspect skin for redness
b. Use a residual limb shrinker
c. Wash the stump with soap and water
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 - ✔b. Administer prescribed diuretic
, 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. Encourage family members to cook meals outdoors and bring the
cooked food inside
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 - ✔B. Limit fluid Intake
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 - ✔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
c. keep head of bed raised 45 degrees
d. assess warmth of extremities - ✔c. keep head of bed raised 45 degrees
The home care nurse provide self-care instruction for a client chronic venous
insufficiency cause by deep vein thrombosis. Which instructions should the nurse
include in the client's discharge teaching plan? Select all that apply
a. Avoid prolonged standing or sitting
