Hesi PN Exit Exam 2023

Hesi PN Exit Exam 2023 1. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for eight hours, how many ml of full-strength feeding will the nurse need? (Enter numeric value only.) – 200 ml . 25 ml of full strength feeding mixed with 25ml of water provided 50ml of half strength. 25ml × 8 hours= 200ml 2. An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? - Apply an external condom catheter 3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement? - Reschedule administration of the antibiotic until after he completes his prayers 4. UAP using a hand sanitzers that is alcohol for 2 minutes - tell that hand sanitizer use is less 2min 5. 5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The child weighs 44 pounds. How many mg of the medication should the nurse administer - Answer: 800 Rationale: First, convert the child's weight to kg: 44 pounds divided by 2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg 6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather than trickles from the vagina. The uterine fundus is firm and the client's vital signs are pulse 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take next? - Compare current vital signs with previous vital signs 7. A 6-year-old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye. Which action should the school nurse take? - Have the parent take the child for emergency help 8. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of "Altered thought processes, secondary to" what condition? - Postpartum psychosis 9. The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual cramps" for a 25-year-old female client. Which self-care activity should the nurse emphasize in the client's teaching plan? - Regular aerobic exercise. 10. Psych/Alcohol/Tylenol overdose antidote - Give Mucomyst 11. Medical Surgical/Laxative abuses - Patient -taking Milk of Magnesium 12. Spiritual/Documentation - Native American - Allow pt's family to stay in the room 13. Leadership- Interpreter informed consent - Pt should sign the consent 14. Geriatrics/Emergency Rib fractures fall - Pulmonary embolism 15. A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client's family? - Involve the client in usual at home activities 16. Upon assessment, the nurse discovers that a postpartum client has persistent red lochia. Which of the following does this assessment finding suggest to the nurse? - Coagulation disorders 17. The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is drained. What action should the nurse complete first? - Assess vital signs. 18. After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? - Clamp the tube 19. The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.; Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000. What should the nurse implement? - Determine if Client B has two units of packed cells available in the blood bank. 20. Triage question with a train wreck the psychiatric nurse is called to a train derailment that was likely caused by a terrorist bomb. In triaging those in need of immediate care, what is the priority ranking for these cases? (arrange these cases in order or priority with the top item requiring the most immediate care and the bottom item requiring the least priority care) - A mother and father have just arrived on the. A crying child being held by another passenger. A woman sitting on the ground with a blanket. A middle-aged man who is wandering around (arrange in order) = middle age woman bleeding- woman w/ blanket- child crying- mother and father. (Mine didn't have a middle age woman bleeding, instead it had an old man wandering and - correct order is: wandering old man, woman w/blanket, man holding baby, and mother & father)