HESI NCLEX EXAM ACTUAL Questions and Answers (2024 / 2025) (Verified Answers)

HESI NCLEX EXAM ACTUAL Questions and Answers (2024 / 2025) (Verified Answers).1. A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. The first action on the part of the nurse is: Calling the physician Inserting an oral airway Turning the client on her side Noting the time of the seizure ANS : C If seizure activity occurs, the nurse remains with the client and presses the emer- gency bell for assistance. The client is turned on her side because a side-lying po- sition permits greater circulation through the placenta and helps prevent aspiration. The nurse then notes the time and sequence of the seizure. The physician is notified that a seizure has occurred, because this is an obstetric emergency associated with cerebral hemorrhage, abruptio placentae, severe fetal hypoxia, and death. No object should be placed in the client's mouth during a seizure. An airway may be inserted after the seizure, and the client's mouth and nose are suctioned to prevent aspiration. Oxygen may be administered by way of face mask during the seizure to increase oxygenation of the placenta and all maternal organs. 2. A nurse reviewing the medical history of an infant experiencing gastroe- sophageal reflux (GER) would expect to note documentation of: Refusal to suck Frequent diarrhea Recurrent otitis media Inability to pass stools ANS : C GER is regurgitation of gastric contents back into the esophagus. The three types of GER are physiologic, functional, and pathologic. Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER. Refusal to suck, diarrhea, and inability to pass stools are not associated with GER.