Hesi rn exit exam

HESI RN Exit Exam C C C




Following discharge teaching, a male client with duodenal ulcer tells the nurse theh
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e will drink plenty of dairy products, such as milk, to help coat and protect his ulce
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r. What is the best follow-up action by the nurse?
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a. Remind the client that it is also important to switch to decaffeinated coffee and
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tea.
b. Suggest that the client also plan to eat frequent small meals to reduce discomfort
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c. Review with the client the need to avoid foods that are rich in milk and cream.
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d. Reinforce this teaching by asking the client to list a dairy food that he might
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select.
(ANS-
CReview with the client the need to avoid foods that are rich in milk andcream
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Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should
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be avoided.
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A male client with hypertension, who received new antihypertensive prescriptions
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at his last visit returns to the clinic two weeks later to evaluate his blood pressure (
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BP). His BP is 158/106 and he admits that he has not been taking the prescribed m
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edication because the drugs make him "feel bad". In explaining the need for hypert
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ension control, the nurse should stress that an elevated BP places the client at risk f
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or which pathophysiological condition?
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a. Blindness secondary to cataracts C C C


b. Acute kidney injury due to glomerular damage
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c. Stroke secondary to hemorrhage
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d. Heart block due to myocardial damage
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(ANS- Stroke secondary to hemorrhage
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Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
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hypertension.

,The nurse observes an unlicensed assistive personnel (UAP) positioning a newly a
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dmitted client who has a seizure disorder. The client is supine and the UAP is placi
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ng soft pillows along the side rails. What action should the nurse implement?
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a. Ensure that the UAP has placed the pillows effectively to protect the client.
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b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of
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pillows.
c. Assume responsibility for placing the pillows while the UAP completes another
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task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying
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position.
(ANS-
CInstruct the UAP to obtain soft blankets to secure to the side rails instead ofpillows
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Rationale: The nurse should instruct the UAP to pad the side rails with soft blanke
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st because the use of pillows could result in suffocation and would need tobe remo
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ved at the onset of the seizure. The nurse can delegate paddling the side rails to the
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CUAP

An adolescent with major depressive disorder has been taking duloxetine (Cy
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mbalta) for the past 12 days. Which assessment finding requires immediatefoll
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ow-up

a. Describes life without purpose C C C


b. Complains of nausea and loss of appetite C C C C C C


c. States is often fatigued and drowsy
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d. Exhibits an increase in sweating. ( C C C C C


ANS- Describes life without purpose
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Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor
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that is known to increase the risk of suicidal thinking in adolescents and young ad
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ults with major depressive disorder. B, C and D are side effects
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,A 60-year-
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old female client with a positive family history of ovarian cancer has developed an
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Cabdominal mass and is being evaluated for possible ovarian cancer.Her Papanicol
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au (Pap) smear results are negative. What information should the nurse include in t
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he client's teaching plan
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a. Further evaluation involving surgery may be needed
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b. A pelvic exam is also needed before cancer is ruled out
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c. Pap smear evaluation should be continued every six month
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d. One additional negative pap smear in six months is needed.
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(ANS- Further evaluation involving surgery may be needed
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Rationale: An abdominal mass in a client with a family history for ovarian cancersh
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ould be evaluated carefully
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A client who recently underwent a tracheostomy is being prepared for discharge to
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home. Which instructions is most important for the nurse to include in the discharg
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e plan?
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a. Explain how to use communication tools.
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b. Teach tracheal suctioning techniques
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c. Encourage self-care and independence. C C C


d. Demonstrate how to clean tracheostomy site. C C C C C C


(ANS- Teach tracheal suctioning techniques
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Rationale: Suctioning helps to clear secretions and maintain an open airway, which
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is critical.
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In assessing an adult client with a partial rebreather mask, the nurse notes that the ox
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ygen reservoir bag does not deflate completely during inspiration and the client'sresp
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iratory rate is 14 breaths / minute. What action should the nurse implement
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a. Encourage the client to take deep breathsC C C C C C


b. Remove the mask to deflate the bag
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c. Increase the liter flow of oxygenC C C C C


d. Document the assessment data C C C

, (ANS- Document the assessment data
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Rationale: reservoir bag should not deflate completely during inspiration and thecli
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ent's respiratory rate is within normal limits.
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During shift report, the central electrocardiogram (EKG) monitoring systemalarms
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. Which client alarm should the nurse investigate first?
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a. Respiratory apnea of 30 seconds C C C C


b. Oxygen saturation rate of 88% C C C C


c. Eight premature ventricular beats every minute
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d. Disconnected monitor signal for the last 6 minutes. C C C C C C C C


(ANS- Respiratory apnea of 30 seconds
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Rationale: The priority is the client whose alarm indicating respiratory apnea thatsho
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uld be assessed first.
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During a home visit, the nurse observed an elderly client with diabetes slip andfa
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ll. What action should the nurse take first?
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a. Give the client 4 ounces of orange juice
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b. Call 911 to summon emergency assistance
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c. Check the client for lacerations or fractures
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d. Asses clients blood sugar level (ANS-
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CCheck the client for lacerations orfractures
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Rationale: After the client falls, the nurse should immediately assess for the
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possibility of injuries and provide first aid as needed
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At 0600 while admitting a woman for a schedule repeat cesarean section (C-
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Section), the client tells the nurse that she drank a cup a coffee at 0400 because she
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wanted to avoid getting a headache. Which action should the nurse take first?
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a. Ensure preoperative lab results are available
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b. Start prescribed IV with lactated Ringer's
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