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101. 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?
a- Slow onset of facial drooping associated with headache
b- Inability to close the affected eye, raise brow, or smile
c- A flat nasolabial fold on the right resulting in facial
asymmetry.
d- Drooling is present on right side of the mouth, but not on the left.Correct
Answerb- Inability to close the affected eye, raise brow, or smile
Rationale: Because the motor function controlling eye closure, brow movement
and smiling are all carried on the 7th cranial (facial) nerve, the combination of
symptoms directly relating to an impairment of all branches of the facial nerve
indicate that Bell‟s palsy has occurred.
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102. 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?
a- Turns to left the side to instill the irrigating solution into the stoma
b- Keeps the irrigating container less than 18 inches above the stoma
c- Instills 1,200 ml of irrigating solution to stimulate bowel evacuation
d- Inserts irrigating catheter deeper into stoma when cramping occursCorrect
Answerb- Keeps the irrigating container less than 18 inches above the stoma
Rationale: Keeping the irrigating container less than 18 inches above the stoma
permits the solution to flow slowly with little excessive peristalsis does not cause
immediate release of stool.
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103. The nurse should teach the client to observe which precaution while taking
dronedarone?
a- Stay out of direct sunlight
b- Avoid grapefruits and its juice
c- Reduce the use of herbal supplements
d- Minimize sodium intake.Correct Answerb- Avoid grapefruits and its juice
Rationale: Grapefruit increase the effect of dronedarone thereby increasing the
possibility of serious side effects. A does not cause a serious effect. C may
potentiate lethal arrhythmias and should be avoided. D does not directly affect
those taking dronedarone.
104. A client who sustained a head injury following an automobile collision is
admitted to the hospital. The nurse includes the client's risk for developing
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increased intracranial pressure (ICP) in the plan of care. Which signs indicate to
the nurse that ICP has increased?
a- Increased Glasgow coma scale score
b- Nuchal rigidity and papilledema
c- Confusion and papilledema
d- Periorbital ecchymosis.Correct Answerc- Confusion and papilledema
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.
105. 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?
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Latest Update .
101. 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?
a- Slow onset of facial drooping associated with headache
b- Inability to close the affected eye, raise brow, or smile
c- A flat nasolabial fold on the right resulting in facial
asymmetry.
d- Drooling is present on right side of the mouth, but not on the left.Correct
Answerb- Inability to close the affected eye, raise brow, or smile
Rationale: Because the motor function controlling eye closure, brow movement
and smiling are all carried on the 7th cranial (facial) nerve, the combination of
symptoms directly relating to an impairment of all branches of the facial nerve
indicate that Bell‟s palsy has occurred.
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Exit Hesi 700 + Bank 101-200 Guaranteed Success Latest Update 2023\2024 Rated A+
Exit Hesi 700 + Bank 101-200 Guaranteed Success Latest Update 2023\2024 Rated A+
,Exit Hesi 700 + Bank 101-200 Guaranteed Success
Latest Update .
102. 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?
a- Turns to left the side to instill the irrigating solution into the stoma
b- Keeps the irrigating container less than 18 inches above the stoma
c- Instills 1,200 ml of irrigating solution to stimulate bowel evacuation
d- Inserts irrigating catheter deeper into stoma when cramping occursCorrect
Answerb- Keeps the irrigating container less than 18 inches above the stoma
Rationale: Keeping the irrigating container less than 18 inches above the stoma
permits the solution to flow slowly with little excessive peristalsis does not cause
immediate release of stool.
Exit Hesi 700 + Bank 101-200 Guaranteed Success Latest Update 2023\2024 Rated A+
Exit Hesi 700 + Bank 101-200 Guaranteed Success Latest Update 2023\2024 Rated A+
Exit Hesi 700 + Bank 101-200 Guaranteed Success Latest Update 2023\2024 Rated A+
,Exit Hesi 700 + Bank 101-200 Guaranteed Success
Latest Update .
103. The nurse should teach the client to observe which precaution while taking
dronedarone?
a- Stay out of direct sunlight
b- Avoid grapefruits and its juice
c- Reduce the use of herbal supplements
d- Minimize sodium intake.Correct Answerb- Avoid grapefruits and its juice
Rationale: Grapefruit increase the effect of dronedarone thereby increasing the
possibility of serious side effects. A does not cause a serious effect. C may
potentiate lethal arrhythmias and should be avoided. D does not directly affect
those taking dronedarone.
104. A client who sustained a head injury following an automobile collision is
admitted to the hospital. The nurse includes the client's risk for developing
Exit Hesi 700 + Bank 101-200 Guaranteed Success Latest Update 2023\2024 Rated A+
Exit Hesi 700 + Bank 101-200 Guaranteed Success Latest Update 2023\2024 Rated A+
Exit Hesi 700 + Bank 101-200 Guaranteed Success Latest Update 2023\2024 Rated A+
, Exit Hesi 700 + Bank 101-200 Guaranteed Success
Latest Update .
increased intracranial pressure (ICP) in the plan of care. Which signs indicate to
the nurse that ICP has increased?
a- Increased Glasgow coma scale score
b- Nuchal rigidity and papilledema
c- Confusion and papilledema
d- Periorbital ecchymosis.Correct Answerc- Confusion and papilledema
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.
105. 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?
Exit Hesi 700 + Bank 101-200 Guaranteed Success Latest Update 2023\2024 Rated A+
Exit Hesi 700 + Bank 101-200 Guaranteed Success Latest Update 2023\2024 Rated A+
Exit Hesi 700 + Bank 101-200 Guaranteed Success Latest Update 2023\2024 Rated A+
