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HESI RN Exam Exit

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When caring for a client in labor, which finding is most important to report to the primary health care provider? A. Maternal heart rate, 90 beats/min B. Fetal heart rate, 100 beats/min C. Maternal blood pressure, 140/86 mm Hg D. Maternal temperature, 100.0°F - correct answerB. Fetal heart rate, 100 beats/min In caring for a pregnant woman with gestational diabetes, the nurse should be alert to which finding? A. A consistent fasting blood sugar level between 80 and 85 mg/dL B. A 2-hour postprandial level 120 mg/dL C. Client reports taking a 30-minute walk after dinner D. Client describes eating pattern of four to six meals daily - correct answerB. A 2-hour postprandial level 120 mg/dL

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HESI RN Exit Exam

HESI RN Exit Exam

Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse
perform as a priority before administering the medication?

A) Checking the client's blood pressure

B) checking the client's peripheral pulses

C) checking the most recent potassium level

D) checking the client's intake and output record for the last 24 hours - correct answerA) Checking the
client's blood pressure



Rationale--enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat
hypertension. One common side effect is postural hypotension. Therefore the nurse would check the
client's blood pressure immediately before administering each dose.



A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
instruction?



A) "The test will take about 30 minutes"

B) "I need to fast for 8 hours before the test"

C) "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the
morning of the test."

D) "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the
test can be constipating." - correct answerC) "I need to drink citrate of magnesia the night before the
test and give myself a Fleet enema on the morning of the test."



Rationale

An upper GI series involves visualization of the esophagus, duodenum, and upper

jejunum by means of the use of a contrast medium. It involves swallowing a contrast

medium (usually barium), which is administered in a flavored milkshake. Films are taken

, HESI RN Exit Exam
at intervals during the test, which takes about 30 minutes. No special preparation is

necessary before a GI series, except that NPO status must be maintained for 8 hours

before the test. After an upper GI series, the client is prescribed a laxative to hasten

elimination of the barium. Barium that remains in the colon may become hard and

difficult to expel, leading to fecal impaction.



A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed
medication is higher than the normal dose. The nurse calls the physician's answering service and is told
that the physician if off for the night and will be available the next morning. The nurse should:

A) call the nursing supervisor

B) Ask the answering service to contact the on-call physician

C) Withhold the medication until the physician can be reached in the morning

D) Administer the medication but consult the physician when he becomes available - correct answerB)
Ask the answering service to contact the on-call physician



An emergency department (ED) nurse is monitoring a client with suspected acute

myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit.

The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the

monitor, checks the client's carotid pulse, and determines that the PVCs are not

resulting in perfusion. The appropriate action by the nurse is:

A. Documenting the findings

B. Asking the ED physician to check the client

C. Continuing to monitor the client's cardiac status
D. Informing the client that PVCs are expected after an MI - correct answerB. Asking the ED physician to
check the client



NPO status is imposed 8 hours before the procedure on a client scheduled to undergo

electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse

checks the client's record and notes that the client routinely takes an oral

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