HESI Exit 5 Exam - 160 Questions and answers Graded A+ 2024/25

HESI Exit 5 Exam - 160 Questions and answers Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement? - Remove cigarettes for the client's room A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.) A.)A client must be willing to accept palliative care, not curative care. B.)The healthcare provider must project that the client has 6 months or less to live. C.)The client must be diagnosed with clinical depression D.)The client must be of sound mind - A,B A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan? - Avoid use of nonsteroidal antinflammatory drugs (NSAID). An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? - Digoxin The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? - Supervise a newly hired graduate nurse during an admission assessment. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take? - Ask the client what he is thinking about at his time. After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.) A.)Administer PRN nebulizer treatment. B.)Obtain 12 lead electrocardiogram. C.)Monitor continuous oxygen saturation. D.) Lay the client in the prone position - A,B,C The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take? - Administer a prescribed analgesia for pain. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child? - Use sunblock or protective clothing when outdoors. Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? SATA A.) Tell the client that its a mild reaction B.)Notify the food services department of the allergy. C.)Enter the allergy information in the client's record. D.)Add egg allergy to the client's allergy arm band. - B,C,D The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement? - Perform bilateral chest auscultation. After administering an antipyretic medication. Which intervention should the nurse implement? - Encouraging liberal fluid intake A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? - Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? - Determine client's pulse, blood pressure, and respirations The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply) A.)Take postoperative vital signs for a client who has an epidual following knee arthroplasty B.)Collect a sputum specimen for a client with a fever of unknown origin C.)Ambulate a client who had a femoral-popliteal bypass graft yesterday - A,B,C A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement? - Raise the head of the bed to a Fowler's position and support his arms with a pillow A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next? - Administer the analgesic as requested The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.) - 12160 A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? A.)Observe aspiration site. B.)Assess body temperature C.)Monitor skin elasticity D.)Measure urinary output - A An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? - Reinforce the importance of annual papanicolaou (Pap) smears. A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first? - Establish a structured routine for the client to follow. A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? - Ventricular arrhythmias. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? - Instruct the mother to change the child's diaper more often. A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement? - Encourage the client to eat finger foods. A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication? - Bowel patterns While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement? - Contact the medical records department supervisor. A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) - 83 While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first? - Submit a referral for an evaluation by a physical therapist. A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement? - Submit a referral for an evaluation by a physical therapist. A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement? - Reposition the client with the head of the bed elevated. 155. After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement? - Hold oral intake until swallow evaluation is done. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply) A.)Interacts with a flat affect. B.)Avoids eye contact. C.)Makes dull eye contact D.)Has a disheveled appearance. - A,B,D A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement? - Transfer the client to the surgical floor. In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A.)Place personal religious artifacts on the body. B.)Attach identifying name tags to the body. C.)Follow cultural beliefs in preparing the body. D.) Inform the family - A,B,C An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions? - Be alert for possible cross-