2024 NGN HESI RN EXIT REAL EXAM V3 WITH 160
QUSTIONS AND ANSWERS (VERIFIED BY EXAM)
• A male client with stomach cancer returns to the unit following a total gastrectomy. He
has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour
IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction
canister, the client’s heart rate is 155 beats/minute, and his blood pressure is 78/48
mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse
implement first?
• Measure and document the client’s urinary output.
• Request the client’s reserved unit if packed red blood cells.
• Prepare the placement of a central venous
catheter.
• d. Increase the infusion rate of Lactated Ringer’s
solution.
• an adult male who fell 20 feet from the roof of this home has multiple injuries, including a
right pneumothorax. Chest tubes were inserted in the emergency department prior to his
transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is
bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright
red blood is measured in the collection chamber. Which intervention should the nurse
implement?
• Add sterile water to the suction control chamber.
• Give blood from the collection chamber as autotransfusion
• Manipulate blood in tubing to drain into chamber.
• Increase wall suction to eliminate fluctuation in water seal.
• A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room
airof 89%. Which action should the nurse take first?
• Elevate the foot of the bed.
• Restrict the client’s
fluid.
• c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.
,• A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation.
Based on the client’s admitting diagnosis, which findings require immediate action by the
nurse?(Select all that apply)
• Headache and tremors
• Irregular heart rate
• Skin hyperpigmentation
• Postural hypotension
• Pallor and diaphoresis
• An older client is admitted with fluid volume deficit and dehydration. Which assessment
findingis the best indicator of hydration that the nurse should report to the healthcare
provider?
• Urine specific gravity is 1.040
• Systolic blood pressure decreases 10 points when standing.
• The client denies being thirsty.
• Skin tenting occurs when the client’s forearm is pinched.
• After an inservice about electronic health record (EHR) security and safeguarding
clientinformation, the nurse observes a colleague going home with printed copies of
client information in a uniform pocket. Which action should the nurse take?
• File a detailed incident report with the specific hiring facility.
• Warn the colleague that their actions are unprofessional.
• Comment anonymously about the action of a staff discussion board.
• Communicate the colleague’s actions to the unit charge nurse.
• The nurse is evaluating a tertiary prevention program for clients with cardiovascular
diseaseimplemented in a rural health clinic. Which outcome indicate the program is
effective?
• At-risk clients received an increased number of routine health screenings.
• Clients reported having new confidence in making healthy food choices.
• Clients who incurred disease complications promptly received rehabilitation.
• Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
,• The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who
usesoxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the
client is having increased shortness of breath with respirations at 23 breaths/minute.
Which action should the nurse implement first?
• Determine if the client is experiencing any anxiety.
• Auscultate the client’s bilateral lung sounds and oxygen saturation.
• Notify the healthcare provider about the client’s distress.
• Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
• Which statement by a client who is 24 hours post-subtotal thyroidectomy requires
animmediate investigation by the nurse?
• “When I get out of bed quickly, I feel a little dizzy.”
• “The dressing over my incision feels like it is too tight.”
• “I’m most comfortable when the head of the bed is raised.”
• “This IV infusion makes me urinate more often than usual.”
• An older adult male who is in his early 70’s is admitted to the emergency department because
ofa COPD exacerbation. This client is struggling to breathe and the healthcare team is
preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the
client, asks thenurse to stop the procedure and provide the nurse a copy of the client’s living
will. Which action should the nurse take?
• Facilitate a family meeting with the palliative care
team.
• b. Notify the healthcare provider of the client’s
wishes.
• Place a certified copy of the living will in the client’s record.
• Alert the nursing staff of the client’s don’t resuscitate status.
• An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client
whose prescribed activity is bedrest with bedside commode use. The UAP reports to the
, nurse that the client is so obese that the UAP feels unable to safely assist the client in
transferring from the bedto the bedside commode. How should the nurse respond?
• Determine the client’s level of mobility and need for assistance.
• Instruct the UAP that all clients deserve equal care.
• Advice the client to maintain bedrest so that safety can be ensured.
• Assign another UAP to care for the client.
• A nurse determines that more than 25% of the students at a middle school are overweight.
Thenurse presents the information at the parent-teacher meeting. What action is most
important for the nurse to include in the meeting?
• Provide information on ways to increase activity for the family.
• Have several teachers talk about health risks associated with
obesity.
• c. Distribute a shopping list of suggested healthy snack
items.
d. Determine the parents’ degree of concern about their children’s weight.
• After several months of chronic fatigue, morning stiffness, and join pain, a young adult is
diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone.
Whicheducation should the nurse provide the client with regard to taking prednisone?
• Take prednisone doses before meals on an empty stomach.
• Wear sunglasses when exposed to bright sunlight.
• If sequential doses are missed, notify the healthcare provider.
• Schedule a monthly laboratory visit for a complete blood count.
• The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the
nurse’s immediate attention?
• A 16-year-old client diagnosed with major depression who refuses to participate in group.
• A 14-year-old client with anorexia nervosa who is refusing to eat the evening
snack.
• c. An 18-year-old client with antisocial behavior who is being yelled at by
other clients
d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby..
QUSTIONS AND ANSWERS (VERIFIED BY EXAM)
• A male client with stomach cancer returns to the unit following a total gastrectomy. He
has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour
IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction
canister, the client’s heart rate is 155 beats/minute, and his blood pressure is 78/48
mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse
implement first?
• Measure and document the client’s urinary output.
• Request the client’s reserved unit if packed red blood cells.
• Prepare the placement of a central venous
catheter.
• d. Increase the infusion rate of Lactated Ringer’s
solution.
• an adult male who fell 20 feet from the roof of this home has multiple injuries, including a
right pneumothorax. Chest tubes were inserted in the emergency department prior to his
transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is
bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright
red blood is measured in the collection chamber. Which intervention should the nurse
implement?
• Add sterile water to the suction control chamber.
• Give blood from the collection chamber as autotransfusion
• Manipulate blood in tubing to drain into chamber.
• Increase wall suction to eliminate fluctuation in water seal.
• A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room
airof 89%. Which action should the nurse take first?
• Elevate the foot of the bed.
• Restrict the client’s
fluid.
• c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.
,• A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation.
Based on the client’s admitting diagnosis, which findings require immediate action by the
nurse?(Select all that apply)
• Headache and tremors
• Irregular heart rate
• Skin hyperpigmentation
• Postural hypotension
• Pallor and diaphoresis
• An older client is admitted with fluid volume deficit and dehydration. Which assessment
findingis the best indicator of hydration that the nurse should report to the healthcare
provider?
• Urine specific gravity is 1.040
• Systolic blood pressure decreases 10 points when standing.
• The client denies being thirsty.
• Skin tenting occurs when the client’s forearm is pinched.
• After an inservice about electronic health record (EHR) security and safeguarding
clientinformation, the nurse observes a colleague going home with printed copies of
client information in a uniform pocket. Which action should the nurse take?
• File a detailed incident report with the specific hiring facility.
• Warn the colleague that their actions are unprofessional.
• Comment anonymously about the action of a staff discussion board.
• Communicate the colleague’s actions to the unit charge nurse.
• The nurse is evaluating a tertiary prevention program for clients with cardiovascular
diseaseimplemented in a rural health clinic. Which outcome indicate the program is
effective?
• At-risk clients received an increased number of routine health screenings.
• Clients reported having new confidence in making healthy food choices.
• Clients who incurred disease complications promptly received rehabilitation.
• Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
,• The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who
usesoxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the
client is having increased shortness of breath with respirations at 23 breaths/minute.
Which action should the nurse implement first?
• Determine if the client is experiencing any anxiety.
• Auscultate the client’s bilateral lung sounds and oxygen saturation.
• Notify the healthcare provider about the client’s distress.
• Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
• Which statement by a client who is 24 hours post-subtotal thyroidectomy requires
animmediate investigation by the nurse?
• “When I get out of bed quickly, I feel a little dizzy.”
• “The dressing over my incision feels like it is too tight.”
• “I’m most comfortable when the head of the bed is raised.”
• “This IV infusion makes me urinate more often than usual.”
• An older adult male who is in his early 70’s is admitted to the emergency department because
ofa COPD exacerbation. This client is struggling to breathe and the healthcare team is
preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the
client, asks thenurse to stop the procedure and provide the nurse a copy of the client’s living
will. Which action should the nurse take?
• Facilitate a family meeting with the palliative care
team.
• b. Notify the healthcare provider of the client’s
wishes.
• Place a certified copy of the living will in the client’s record.
• Alert the nursing staff of the client’s don’t resuscitate status.
• An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client
whose prescribed activity is bedrest with bedside commode use. The UAP reports to the
, nurse that the client is so obese that the UAP feels unable to safely assist the client in
transferring from the bedto the bedside commode. How should the nurse respond?
• Determine the client’s level of mobility and need for assistance.
• Instruct the UAP that all clients deserve equal care.
• Advice the client to maintain bedrest so that safety can be ensured.
• Assign another UAP to care for the client.
• A nurse determines that more than 25% of the students at a middle school are overweight.
Thenurse presents the information at the parent-teacher meeting. What action is most
important for the nurse to include in the meeting?
• Provide information on ways to increase activity for the family.
• Have several teachers talk about health risks associated with
obesity.
• c. Distribute a shopping list of suggested healthy snack
items.
d. Determine the parents’ degree of concern about their children’s weight.
• After several months of chronic fatigue, morning stiffness, and join pain, a young adult is
diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone.
Whicheducation should the nurse provide the client with regard to taking prednisone?
• Take prednisone doses before meals on an empty stomach.
• Wear sunglasses when exposed to bright sunlight.
• If sequential doses are missed, notify the healthcare provider.
• Schedule a monthly laboratory visit for a complete blood count.
• The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the
nurse’s immediate attention?
• A 16-year-old client diagnosed with major depression who refuses to participate in group.
• A 14-year-old client with anorexia nervosa who is refusing to eat the evening
snack.
• c. An 18-year-old client with antisocial behavior who is being yelled at by
other clients
d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby..
