ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)

ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take? Administer the medication as prescribed with a glass of water 272. Which client should the nurse assess frequently because of the risk for overflow incontinence? A client Who is confused and frequently forgets to go to the bathroom 273. While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply) Move obstacle away from client Monitor physical movements Observe for a patent airway Record the duration of the seizure 274. A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care? Observe for changes in level of consciousness. 275. An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required? Increase ventilator rate. 276. The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide? CPT should be performed more frequently, but at least an hour before meals. 277. The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension? Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie 278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care? Fingerstick glucose assessment q6h with meals Review with the client proper foot care and prevention of injury Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous injection technique, site rotation and insulin management 279. Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse? Muscle pain 280. While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? Provide supplemental oxygen Auscultate bilateral lung fields Reinforce occlusive CT dressing 281. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? Ensure that the knot can be quickly released. 282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution? Have the child lie with the ear up for one to two minute after installation. 283. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? Restrict daily fluid intake. 284. The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next? Leave the catheter in place and obtain a sterile catheter. 285. A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Prepare the skin for procedure. 286. Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take? Restrict unvaccinated children from attending school until measles outbreak is resolved. 287. A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? Continue with the plan of care for this client 288. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? Begin to show signs of improvement in affect 289. When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? Check for a destined bladder 290. A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? Encourage popsicles and fluids of choice 291. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? Palpate the client's suprapubic area for distention 292. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include? Divide the medication into two injection with volumes under 1ml 293. A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? Research indicates that mirror therapy is effective in reducing phantom limb pain 294. An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? Notify healthcare provider to prepare for pericardiocentesis 295. A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take? Ask the new person to move belonging to accommodate others 296. The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? Poor feeding and vomiting Leakage of CSF from the incisional site Abdominal distention 297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only) 8 298. In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care? Evaluate closet proximal pulse. 299. The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take? Remove the heating pads and place a soft blanket over the client's leg and feet. 300. A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client? Plan volume-controlled evenly-space meal thorough the day 301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? Insensible loss of body fluids contributes to the hemoconcentration of serum solutes 302. During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN) Prepare a woman for a bone density screening 303. An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take? Send family to the waiting area while the client's history is taking 304. An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority? Imbalance nutrition 305. The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? Avoid crowds for first two months after surgery. 306. The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up is needed for problems associated with chronic hypoxia? Image 307. A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement? Assess compliance with routine prescriptions. 308. The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is Three days postoperative colon resection receiving transfusion of packed RBCs. 309. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching? Avoid straining at stool, bending, or lifting heavy objects. 310. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10 mEq/5ml." how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.) 12.5 311. At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? Place a wedge under the client's right hip. 312. A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? Titrate the dopamine infusion to raise the BP. 313. The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam? Evaluate the client's mood, cognition and orientation. 314. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) Administer a daily dose of lisinopril as scheduled. Provide a PRN dose of acetaminophen for headache 315. When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply) Pasta, noodles, rice. Egg, tofu, ground meat. Mashed, potatoes, pudding, milk. 226. An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? Review the client's serum calcium level 227. A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse? Provide an opportunity for him to clarify his values related to the decision 228. A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client's discharge teaching plan? Weigh every morning 229. A woman just learned that she was infected with Heliobacter pylori. Based on this finding, which health promotion practice should the nurse suggest? Encourage screening for a peptic ulcer 230. 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? Teach tracheal suctioning techniques 231. A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? Cardiac rhythm and heart rate. 232. The nurse note a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? Engage the client in a non-threatening conversation. 233. A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider? Persistent fever 234. The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes? The hemoglobin A1C was 6.5g/100 ml last week 235. An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? Ask the wife to stop and assess the client's swallowing reflex 236. A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next? Begin parenteral antibiotic therapy 237. The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? Recommend weigh bearing physical activity 238. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next? Administer the analgesic as requested 239. A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? Send stool sample to the lab for a guaiac test 240. The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? Brain damage with CP is not progressive but does have a variable course 241. In early septic shock states, what is the primary cause of hypotension? Peripheral vasodilation 242. A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? Allopurinol (Zyloprim) 243. A male client's laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client's plan of care? Encourage him to use an electric razor 244. A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? Persistent coughing while drinking 245. At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation: Remove sequential compression devices. 246. Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? Sudden dysphagia 247. A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? Administer the Zofran after flushing the saline lock with saline 248. When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client? Low fat 249. A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? Muffled heart sounds 250. When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? Place cardiac monitor leads on the client's chest. 251. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? Redress the abdominal incision 252. An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)? Lethargy 253. In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? Enable clients to become active participating in controlling the disease process 254. To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented? Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. 255. The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding? Supplemental feedings with formula 256. Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? Distal pulse intensity 257. An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse's response should be based on which information about assistive devices? They decrease the risk for joint trauma 258. When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? Sitting upright. 259. A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching? Avoid all isometric exercises, but walk regularly. 260. What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? Initiate the dosage lockout mechanism on the PCA pump 261. While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first? Raise the client's legs and feet 262. The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? Heat loss 263. The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first? Tell the staff to keep all clients and visitors in the client rooms with the doors closed 264. A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client's history is a possible contraindication for the use of HRT? Her mother and sister have a history of breast cancer 265. A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is "starving" because he has had no "real food" since before the surgery. Prior to advancing his diet, which intervention should the nurse implement? Auscultate bowel sounds in all four quadrants 266. The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? A family member of a client with dementia who has been missing for five hours 267. During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client's multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is receiving report implement these interventions? (Arrange from first action on top to last on the bottom). 1. Assess the client's skin and circulation for impairment related to the restrains 2. Evaluate the client's mentation to determine need to continue the restrains 3. Assign unlicensed assistive personnel to remove restrains and remain with client 4. Contact the client's surgeon and primary healthcare provider 268. A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first? Notify the healthcare provider and obtain a tracheostomy tray 269. After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first? Epinephrine Injection, USP IV 270. Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first? Evaluate both client's pain using a standardized pain scale 586. A client who is schedule for an elective inguinal hernia repair today in day surgery is seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications? Explain that vomiting can occur during surgery Withhold the preoperative medication 587. The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide? Exercise at least three times weekly 588. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? Perform a sterile vaginal exam 589. The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit? Dyspnea, cough, and fatigue. 590. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement? Acknowledge the client's stress and suggest that she consider respite care. 591. The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take? Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern. 592. A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider? Muscle cramping 593. In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? Orthopnea 594. The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate? Inability of the SA node to initiate an impulse at the normal rate 595. The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide? Apply downward manual pressure at the suprapubic regions. 596. A 35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery? The client will be restricted from eating seafood 597. A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? Assist the client to sharply flex her thighs up again the abdomen. 598. The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic? Narrow therapeutic index. 599. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? Decrease abdominal girth 600. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do? Get a blood pressure cuff. 601. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement? Document the finding in the infant's record. 602. Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests? Expresses an understanding of the procedure. 603. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement? Infuse sodium chloride 0.9% (normal saline) 604. The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress? Contractions of the sternocleidomastoid muscle 605. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?