NURS 711 HESI Exit Exam | Verified Questions and Answer and Rationale 2023

NURS 711 HESI Exit Exam | Verified Questions and Answer 2023 While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement? - answerPromptly remove the arterial catheter from the radial artery. A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor? - answer- Rapid onset of decreased level of consciousness. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan? - answer- Report any signs of cloudy urine output. After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take? - answer- Apply light pressure over the area. The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture. What action should the nurse take? - answer- Reposition the restraint tie onto the bedframe. A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse? - answer- Diminished left lower lobe sounds Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re-inflate the lung. The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom) - answer- Arterial endothelium injury causes inflammation Macrophages consume low density lipoprotein (LDL), creating foam cells Foam cells release growth factors for smooth muscle cells Smooth muscle grows over fatty streaks creating fibrous plaques Vessel narrowing results in ischemia Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider? - answerOliguria signals tubular necrosis related to hypoperfusion A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective? - answer- Skills of staff and client acuity When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? - answer- Explain that the client may be placed in five positions A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke? - answer- Inability to close the affected eye, raise brow, or smile The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching? - answer- Keeps the irrigating container less than 18 inches above the stoma The nurse should teach the client to observe which precaution while taking dronedarone? - answer- Avoid grapefruits and its juice A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? - answer- Increased Glasgow coma scale score. Nuchal rigidity and papilledema. Confusion and papilledema Periorbital ecchymosis. Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP. The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection? - answer- Confirm the necessity for continued use of the CVC. During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)? - answer- Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first? - answer- Stop the normal saline infusion. An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care? - answer- Ensure proper alignment of the leg in traction. A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider? - answer- Reassess readiness for SNF transfer. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) - answerRecognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcare provider. Take Glucophage with the morning and evening meal. The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply - answer- Written at a twelfth grade reading level Contains a list with definitions of unfamiliar terms Uses common words with few Syllables Printed using a 12 point type font Uses pictures to help illustrate complex ideas Rationale: During the aging process older clients often experience sensory or cognitive changes, such as decreased visual or hearing acuity, slower thought or reasoning processes, and shorter attention span. Materials for this age group should include at least of terms, such as a medical terminology that incline may not know and use common words that expresses information clearly and simply. Simple, attractive pictures help hold the learner's attention. The reading level of material should be at the 4th to 5th grade level. Materials should be printed using large font (18-point or higher), not the standard 12-point font. . . . . . . . . .