HESI ADN EXIT HESI Simplified Exam Questions And Answers STUDYPACK Latest Update 2024

A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? • • A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? • • A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question should nurse to ask? • • After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? • • After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are legal implications of the nurse’s signature on the client’s surgical consent form? (sata) • • • • Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. Charge nurse implement what? • A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? • • The client with which type of wound is most likely to need immediate intervention by the nurse? • • The nurse is planning care for client admitted with a diagnosis of pheochromocytoma. Intervention? • Monitor blood pressure frequently • When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? • • When assessing a mildly obese 35-year-old female, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? • Ask the client to discuss “do not resuscitate” with her healthcare provider Capillary refill of 8 seconds • Advise the client that assignments are not based on clients requests Place the implant in a lead container using long-handled forceps Laceration To reduce abdominal pressure on the diaphragm • Review with the client the need to avoid foods that are rich in milk and cream • Stroke secondary to hemorrhage Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. • A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? • • An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? • • A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication? • • Which client is at the greatest risk for developing delirium? • • Which intervention should the nurse include in a long-term plan of care for a client with COPD? • • Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? • • A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling “very tired”. Most important intervention to implement? • • Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? • A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? • The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? • An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? • Describes life without purpose Inform her that some antianxiety medications are safe to take while breastfeeding Start an intravenous (IV) infusion of normal saline The additive effect of multiple medications has caused the blood pressure to drop too low An adult client who cannot sleep due to constant pain. Reduce risks factors for infection A business and professional women’s group Measure Vital signs • Further evaluation involving surgery may be needed • Teach tracheal suctioning techniques • Document the assessment data • Check the client for lacerations or fractures • A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client’s teaching plan? • A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? • In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement? • During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which alarm investigate first? • During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action is taken first? • At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action is taken first? • After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? • A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? • Medicare • Listen with the bell at the same location • Inform the anesthesia care provider • Respiratory apnea of 30 seconds