HESI Comprehensive Exit Exam Practice Answered A+ Solution Guide;

1. A client returns to the unit after abdominal Nissen fundoplication for treat- ment of gastroesophageal reflux disease. After 4 hours, the nurse determines the client has no drainage from the nasogastric tube (NGT) and has absent bowel sounds. What action should the nurse implement? Notify the healthcare provider. Continue to monitor the client. Reposition the nasogastric tube. Irrigate the NGT with normal saline. ANS Irrigate the NGT with normal saline. Rationale After abdominal surgery, patency of the NGT should be maintained to avoid the need to reinsert the tube, which could possibility perforate the surgical repair site, so irrigation of the NGT should be implemented to promote gastric drainage and decompression. 2. A client is admitted with myasthenia gravis (MG). During the admission assessment, the nurse identifies that the client's upper eyelids are drooping. Which term should the nurse document to describe this assessment finding? Ptosis. Myopia. Keratitis. Astigmatism. ANS Ptosis. Rationale Ptosis, a hallmark finding in MG, describes drooping of the eyelids associated with neuromuscular disorders, such as MG, a chronic disease from an autoimmune response that destroys acetylcholine receptors and affects the neuromuscular junc- tion.Myopia is nearsightedness. Keratitis is inflammation of the cornea. Astigmatism is a refractive condition