HESI 799 RN EXIT EXAM COMPLETE
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
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. - ANSWER 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.
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
occurs - ANSWER 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.
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. - ANSWER b. 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.
A client who sustained a head injury following an automobile
collision is admitted to the hospital. The nurse include the
client's risk for developing 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. - ANSWER 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.
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?
a. Remind staff to follow protective environment precautions
, b. Gently flush the catheter lumen with sterile saline solution
c. Cleanse the site and change the transparent dressing.
d. Confirm the necessity for continued use of the CVC. -
ANSWER Confirm the necessity for continued use of the CVC
Rationale: Increase the length of use increase the risk for
infection. The CVC care bundle includes the review of the need
for continued use of the CVC. Effective hand hygiene and
standard precautions should be maintained but protective
environment precautions are not needed. B is not needed if
continuous IV fluid are infused, ad may introduce
contaminants. Use of a transparent dressing allows the site to
be visualized for any signs of infection but changing the
dressing daily increases the risk for infection.
During an annual physical examination, an older woman's
fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8
mmol/L (SI). Which additional finding obtained during a follow-
up visit 2 weeks later is most indicative that the client has
diabetes mellitus (DM)?
a. An increased thirst with frequent urination
b. Blood glucose range during past two weeks was 110 to 125
mg/dl or 6.1 to 7.0 mmol/L(SI)
c. Two-hour postprandial glucose tolerance test (GTT) is 160
mg/dL or 8.9 mmol/L (SI)
d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4
mmol/L (SI). - ANSWER Repeated fasting blood sugar (FBS) is
132 mg/dl or 7.4 mmol/L (SI).
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
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. - ANSWER 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.
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
occurs - ANSWER 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.
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. - ANSWER b. 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.
A client who sustained a head injury following an automobile
collision is admitted to the hospital. The nurse include the
client's risk for developing 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. - ANSWER 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.
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?
a. Remind staff to follow protective environment precautions
, b. Gently flush the catheter lumen with sterile saline solution
c. Cleanse the site and change the transparent dressing.
d. Confirm the necessity for continued use of the CVC. -
ANSWER Confirm the necessity for continued use of the CVC
Rationale: Increase the length of use increase the risk for
infection. The CVC care bundle includes the review of the need
for continued use of the CVC. Effective hand hygiene and
standard precautions should be maintained but protective
environment precautions are not needed. B is not needed if
continuous IV fluid are infused, ad may introduce
contaminants. Use of a transparent dressing allows the site to
be visualized for any signs of infection but changing the
dressing daily increases the risk for infection.
During an annual physical examination, an older woman's
fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8
mmol/L (SI). Which additional finding obtained during a follow-
up visit 2 weeks later is most indicative that the client has
diabetes mellitus (DM)?
a. An increased thirst with frequent urination
b. Blood glucose range during past two weeks was 110 to 125
mg/dl or 6.1 to 7.0 mmol/L(SI)
c. Two-hour postprandial glucose tolerance test (GTT) is 160
mg/dL or 8.9 mmol/L (SI)
d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4
mmol/L (SI). - ANSWER Repeated fasting blood sugar (FBS) is
132 mg/dl or 7.4 mmol/L (SI).
