HESI RN EXIT EXAM V1 Rated A+

1 the nurse is caring for a group of clients with the help of a practical nurse. Which nursing actions should the nurse assigned to the PN? – 1 perform daily surgical dressing change for a client who had an abdominal hysterectomy 2 obtain post-operative vital signs for a client one day following unilateral knee arthroplasty 3 administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus 2 A lethargic one hour old infant is brought to the nursery for further assessment. In what order should the nurse assess this infant? – 1 Heart rate 2 respirations 3 temperature 4 heel stick 3 following a gunshot wound, an adult client has a hemoglobin level of 4. The nurse prepares to administer a unit of blood for an emergency transfusion. The client has ab negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is no type Ab negative blood currently available. Which intervention should the nurse implement? - administering normal saline solution until type Ab negative is available 4 a female client receives a prescription for alendronate sodium (Fusamax) to treat her newly diagnosed osteoporosis. What instructions should the nurse include in the client teaching plan? - take on an empty stomach with a full glass of water 5 a male client with cirrhosis has jaundice and Puritas. He tells the nurse that he has been soaking in hot bath at night with no relief of his discomfort. What action should the nurse take? - encourage the client to use cooler water and apply calamine lotion after soaking 6 an adult female tells the nurse that her grandmother was diagnosed with colorectal cancer at age 75. The client is implementing measures to reduce her own risk. Which of the clients plans indicates the need for additional information? - annual sigmoidoscopy screening 7 a mother runs into the emergency department with a toddler in her arms and tell the nurse that her child got into some cleaning products. The child smells of chemicals on the hands face and the front of the child's clothing. After ensuring an patent Airway, what action should the nurse Implement first? - determine type of chemical exposure8 the nurse enters the room of a client with Parkinson's disease who is taking levodopa. The client is a rising slowly from the chair while the UAP stands next to the chair. What action should the nurse take? - a firm that the client should arrive slowly from the chair 9 a middle-aged female client tells the clinic nurse that she has lost an inch of height in the last year. What is the priority nursing intervention? - assist the client to schedule a bone density exam 10 an atypical antipsychotic, ziprasidone, is prescribed for a client with a diagnosis of schizophrenia. After the client has been taking the medication for two weeks, the nurse assesses the Drug's effectiveness. which client reports suggest that the medication is helpful? - hears voices less often 11 prior to obtaining a trapeze bar for a client with limited Mobility, which client assessment is most important for the nurse to obtain? - upper body muscle strength 12 a male client with heart failure reports heart palpitations and difficulty breathing when lying flat. When he requests additional pillows, the nurse determines that his heart rate is 125 beats per minute and respiratory rate is 22 breaths per minute. Which intervention is most important for the nurse to implement? - obtain manual blood pressure 13 a family member reports that the client who is bedridden has not been turned or repositioned all night and is sleeping on a special air mattress with no sheets. What information should the nurse provide to the family member? - clarify that an aerated support surface does not use sheets that often cause skin breakdown 14 an S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? - document in the client's record 15 the nurse is evaluating the diet teaching of a client with hypertension. What dinners selection indicates that the client understands the dietary recommendations for hypertension? - baked pork chop, apple sauce, corn on the cob, 1% milk, and key lime pie 16 a client who had a percutaneous coronary intervention two weeks ago returns to the clinic for a follow-up visit. The client had a post-operative ejection fraction of 30%. Today the client has lungs which are clear, slight pedal edema, and a 5 pound weight gain. Which interventions should the nurse implement? - assess compliance with routine prescriptions 17 the nurse is completing an admission assessment for a male client with paranoid schizophrenia. The client tells the nurse that the staff dislikes him. What action should the nurse take? - determine if the client has formulated any plans regarding the staff18 an adult male was diagnosed with stage 4 lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse? - explain that the client will start to lose consciousness and his body systems will slow down 19 a client with a history of adrenal insufficiency is admitted to the ICU with an acute adrenal crisis. the client is complaining of nausea and joint pain. Vital signs are temperature 102, heart rate 138, BP 80 / 60. which intervention should the nurse Implement first? - Infuse an intravenous fluid bolus 20 following morning care, a client with a C5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse Implement first? - relieve any kinks or obstruction in the clients Foley tubing