3/6/24,B9:13BP HESIBRNBEXITBEXAMBV3B-
M BHESIBexit
HESI RN EXIT
EXAM 2022 V3
B B
160 Q&A
B
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1. ABmaleBclientBwithBstomachBcancerBreturnsBtoBtheBunitBfollowingBaBtotalBgastrectomy.BH
eBhasBaBnasogastricBtubeBtoBsuctionBandBisBreceivingBLactatedBRinger’sBsolutionBatB75BmL
/hourBIV.BOneBhourBafterBadmissionBtoBtheBunit,BtheBnurseBnotesB300BmLBofBbloodBinBth
eBsuctionBcanister,BtheBclient’sBheartBrateBisB155Bbeats/minute,BandBhisBbloodBpressureBi
sB78/48BmmHg.BInBadditionBtoBreportingBtheBfindingBtoBtheBsurgeon.BWhichBactionBshoul
dBtheBnurseBimplementBfirst?
a. MeasureBandBdocumentBtheBclient’sBurinaryBoutput.
b. RequestBtheBclient’sBreservedBunitBifBpackedBredBbloodBcells.
c. PrepareB theB placementB ofB aB centralB venousB catheter.
d. IncreaseBtheBinfusionBrateBofBLactatedBRinger’sBsolution.
2. anBadultBmaleBwhoBfellB20BfeetBfromBtheBroofBofBthisBhomeBhasBmultipleBinjuries,Bincluding
BaBrightBpneumothorax.BChestBtubesBwereBinsertedBinBtheBemergencyBdepartmentBpriorBtoB
hisBtransferBtoBtheBintensiveBcareBunitB(ICU).BtheBnurseBnotesBthatBtheBsuctionBcontrolBcham
berBisBbubblingBatBthe
-
B10BcmBH2OBmark,BwithBfluctuationBinBtheBwaterBseal,BandBoverBtheBpastBhourB75BmlBofBbr
ightBredBbloodBisBmeasuredBinBtheBcollectionBchamber.BWhichBinterventionBshouldBtheBnurse
Bimplement?
a. AddBsterileBwaterBtoBtheBsuctionBcontrolBchamber.
b. GiveBbloodBfromBtheBcollectionBchamberBasBautotransfusion
c. ManipulateBbloodBinBtubingBtoBdrainBintoB chamber.
d. IncreaseBwallBsuctionBtoBeliminateBfluctuationBinBwaterBseal.
3. ABclientBwhoBreceivedBhemodialysisByesterdayBisBexperiencingBaBbloodBpressureBofB200/100
BmmHg,BheartBrateB110Bbeats/minute,BandBrespiratoryBrateB36Bbreaths/minute.BTheBclientBi
sBmanifestingBshortnessB ofBbreath,BbilateralB2+BpedalBedema,BandBanB oxygenBsaturationBonB
roomBairBofB89%.BWhichBactionBshouldBtheBnurseBtakeBfirst?
a. ElevateBtheBfootBofBtheBbed.
b. RestrictBtheB client’sB fluid.
c. BeginBsupplementalBoxygen.
d. PrepareBtheBclientBforBhemodialysis.
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4. ABclientBwithBAddison’sBcrisisBisBadmittedBforBtreatmentBwithBadrenalBcorticalBsupplementati
on.BBasedBonBtheBclient’sBadmittingBdiagnosis,BwhichBfindingsBrequireBimmediateBactionBbyBt
heBnurse?B(SelectBallBthatBapply)
a. HeadacheBandBtremors
b. IrregularBheartBrate
c. SkinBhyperpigmentation
d. PosturalBhypotension
e. PallorBandBdiaphoresis
5. AnBolderBclientBisBadmittedBwithBfluidBvolumeBdeficitBandBdehydration.BWhichBassessmentBf
indingBisBtheBbestBindicatorBofBhydrationBthatBtheBnurseBshouldBreportBtoBtheBhealthcare Bpr
ovider?
a. UrineBspecificBgravityBisB1.040
b. SystolicBbloodBpressureBdecreasesB10B pointsBwhenBstanding.
c. TheBclientBdeniesBbeingBthirsty.
d. SkinBtentingBoccursBwhenBtheBclient’sBforearmBisBpinched.
6. AfterBanBinserviceBaboutBelectronicBhealthBrecordB(EHR)BsecurityBandBsafeguardingB
clientBinformation,BtheBnurseB observesBaBcolleagueBgoingBhomeBwithBprintedBcopies
BofBclientBinformationBinBaBuniformBpocket.BWhichBactionBshouldBtheBnurseBtake?
a. FileBaBdetailedBincidentBreportBwithBtheBspecificBhiringBfacility.
b. WarnBtheBcolleagueBthatBtheirBactionsBareBunprofessional.
c. CommentBanonymouslyBaboutBtheBactionBofBaBstaffBdiscussionBboard.
d. CommunicateBtheBcolleague’sBactionsBtoBtheBunitBchargeBnurse.
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M BHESIBexit
7. TheBnurseBisBevaluatingBaBtertiaryBpreventionBprogramB forBclientsBwithBcardiovascularBdi
seaseBimplementedBinBaBruralBhealthBclinic.BWhichBoutcomeBindicateBtheBprogramBisBeffe
ctive?
a. At-riskBclientsBreceivedBanBincreasedBnumberBofBroutineBhealthBscreenings.
b. ClientsBreportedBhavingBnewBconfidenceBinBmakingBhealthyBfoodBchoices.
c. ClientsBwhoBincurredBdiseaseBcomplicationsB promptlyBreceivedBrehabilitation.
d. ClientBrelapseBrateBofB30%BinBaB5-yearBcommunity-wideBanti-smokingBcampaign.
8. TheBnurseBisBcaringBforBaBclientBwithBchronicBobstructiveBpulmonaryBdiseaseB(COPD)Bwh
oBusesBoxygenBatB2BL/minuteBperBnasalBcannulaBcontinuously.BTheBnurseBobservesBthatB
theBclientBisBhavingBincreasedBshortnessBofB breathBwithBrespirationsBatB23Bbreaths/minu
te.BWhichBactionBshouldBtheBnurseBimplementBfirst?
a. DetermineBifBtheBclientBisBexperiencingBanyBanxiety.
b. AuscultateBtheBclient’sBbilateralBlungBsoundsBandBoxygenBsaturation.
c. NotifyBtheBhealthcareBproviderBaboutBtheBclient’sBdistress.
d. AssessBtheB deliveryBmechanismBofBtheBoxygenBtank,Btubing,BandBcannula.
9. WhichBstatementBbyBaBclientBwhoBisB24BhoursBpost-
subtotalBthyroidectomyBrequiresBanBimmediateBinvestigationBbyBtheBnurse?
a. “WhenBIBgetBoutBofBbedBquickly,BIBfeelBaBlittleBdizzy.”
b. “TheBdressingBoverBmyBincisionBfeelsBlikeBitBisBtooBtight.”
c. “I’mBmostBcomfortableBwhenBtheBheadBofBtheBbedBisBraised.”
d. “ThisBIVBinfusionBmakesBmeBurinateBmoreBoftenBthanBusual.”
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M BHESIBexit
HESI RN EXIT
EXAM 2022 V3
B B
160 Q&A
B
about:blank 1/37
,3/6/24,B9:13BP HESIBRNBEXITBEXAMBV3B-
M BHESIBexit
1. ABmaleBclientBwithBstomachBcancerBreturnsBtoBtheBunitBfollowingBaBtotalBgastrectomy.BH
eBhasBaBnasogastricBtubeBtoBsuctionBandBisBreceivingBLactatedBRinger’sBsolutionBatB75BmL
/hourBIV.BOneBhourBafterBadmissionBtoBtheBunit,BtheBnurseBnotesB300BmLBofBbloodBinBth
eBsuctionBcanister,BtheBclient’sBheartBrateBisB155Bbeats/minute,BandBhisBbloodBpressureBi
sB78/48BmmHg.BInBadditionBtoBreportingBtheBfindingBtoBtheBsurgeon.BWhichBactionBshoul
dBtheBnurseBimplementBfirst?
a. MeasureBandBdocumentBtheBclient’sBurinaryBoutput.
b. RequestBtheBclient’sBreservedBunitBifBpackedBredBbloodBcells.
c. PrepareB theB placementB ofB aB centralB venousB catheter.
d. IncreaseBtheBinfusionBrateBofBLactatedBRinger’sBsolution.
2. anBadultBmaleBwhoBfellB20BfeetBfromBtheBroofBofBthisBhomeBhasBmultipleBinjuries,Bincluding
BaBrightBpneumothorax.BChestBtubesBwereBinsertedBinBtheBemergencyBdepartmentBpriorBtoB
hisBtransferBtoBtheBintensiveBcareBunitB(ICU).BtheBnurseBnotesBthatBtheBsuctionBcontrolBcham
berBisBbubblingBatBthe
-
B10BcmBH2OBmark,BwithBfluctuationBinBtheBwaterBseal,BandBoverBtheBpastBhourB75BmlBofBbr
ightBredBbloodBisBmeasuredBinBtheBcollectionBchamber.BWhichBinterventionBshouldBtheBnurse
Bimplement?
a. AddBsterileBwaterBtoBtheBsuctionBcontrolBchamber.
b. GiveBbloodBfromBtheBcollectionBchamberBasBautotransfusion
c. ManipulateBbloodBinBtubingBtoBdrainBintoB chamber.
d. IncreaseBwallBsuctionBtoBeliminateBfluctuationBinBwaterBseal.
3. ABclientBwhoBreceivedBhemodialysisByesterdayBisBexperiencingBaBbloodBpressureBofB200/100
BmmHg,BheartBrateB110Bbeats/minute,BandBrespiratoryBrateB36Bbreaths/minute.BTheBclientBi
sBmanifestingBshortnessB ofBbreath,BbilateralB2+BpedalBedema,BandBanB oxygenBsaturationBonB
roomBairBofB89%.BWhichBactionBshouldBtheBnurseBtakeBfirst?
a. ElevateBtheBfootBofBtheBbed.
b. RestrictBtheB client’sB fluid.
c. BeginBsupplementalBoxygen.
d. PrepareBtheBclientBforBhemodialysis.
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4. ABclientBwithBAddison’sBcrisisBisBadmittedBforBtreatmentBwithBadrenalBcorticalBsupplementati
on.BBasedBonBtheBclient’sBadmittingBdiagnosis,BwhichBfindingsBrequireBimmediateBactionBbyBt
heBnurse?B(SelectBallBthatBapply)
a. HeadacheBandBtremors
b. IrregularBheartBrate
c. SkinBhyperpigmentation
d. PosturalBhypotension
e. PallorBandBdiaphoresis
5. AnBolderBclientBisBadmittedBwithBfluidBvolumeBdeficitBandBdehydration.BWhichBassessmentBf
indingBisBtheBbestBindicatorBofBhydrationBthatBtheBnurseBshouldBreportBtoBtheBhealthcare Bpr
ovider?
a. UrineBspecificBgravityBisB1.040
b. SystolicBbloodBpressureBdecreasesB10B pointsBwhenBstanding.
c. TheBclientBdeniesBbeingBthirsty.
d. SkinBtentingBoccursBwhenBtheBclient’sBforearmBisBpinched.
6. AfterBanBinserviceBaboutBelectronicBhealthBrecordB(EHR)BsecurityBandBsafeguardingB
clientBinformation,BtheBnurseB observesBaBcolleagueBgoingBhomeBwithBprintedBcopies
BofBclientBinformationBinBaBuniformBpocket.BWhichBactionBshouldBtheBnurseBtake?
a. FileBaBdetailedBincidentBreportBwithBtheBspecificBhiringBfacility.
b. WarnBtheBcolleagueBthatBtheirBactionsBareBunprofessional.
c. CommentBanonymouslyBaboutBtheBactionBofBaBstaffBdiscussionBboard.
d. CommunicateBtheBcolleague’sBactionsBtoBtheBunitBchargeBnurse.
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M BHESIBexit
7. TheBnurseBisBevaluatingBaBtertiaryBpreventionBprogramB forBclientsBwithBcardiovascularBdi
seaseBimplementedBinBaBruralBhealthBclinic.BWhichBoutcomeBindicateBtheBprogramBisBeffe
ctive?
a. At-riskBclientsBreceivedBanBincreasedBnumberBofBroutineBhealthBscreenings.
b. ClientsBreportedBhavingBnewBconfidenceBinBmakingBhealthyBfoodBchoices.
c. ClientsBwhoBincurredBdiseaseBcomplicationsB promptlyBreceivedBrehabilitation.
d. ClientBrelapseBrateBofB30%BinBaB5-yearBcommunity-wideBanti-smokingBcampaign.
8. TheBnurseBisBcaringBforBaBclientBwithBchronicBobstructiveBpulmonaryBdiseaseB(COPD)Bwh
oBusesBoxygenBatB2BL/minuteBperBnasalBcannulaBcontinuously.BTheBnurseBobservesBthatB
theBclientBisBhavingBincreasedBshortnessBofB breathBwithBrespirationsBatB23Bbreaths/minu
te.BWhichBactionBshouldBtheBnurseBimplementBfirst?
a. DetermineBifBtheBclientBisBexperiencingBanyBanxiety.
b. AuscultateBtheBclient’sBbilateralBlungBsoundsBandBoxygenBsaturation.
c. NotifyBtheBhealthcareBproviderBaboutBtheBclient’sBdistress.
d. AssessBtheB deliveryBmechanismBofBtheBoxygenBtank,Btubing,BandBcannula.
9. WhichBstatementBbyBaBclientBwhoBisB24BhoursBpost-
subtotalBthyroidectomyBrequiresBanBimmediateBinvestigationBbyBtheBnurse?
a. “WhenBIBgetBoutBofBbedBquickly,BIBfeelBaBlittleBdizzy.”
b. “TheBdressingBoverBmyBincisionBfeelsBlikeBitBisBtooBtight.”
c. “I’mBmostBcomfortableBwhenBtheBheadBofBtheBbedBisBraised.”
d. “ThisBIVBinfusionBmakesBmeBurinateBmoreBoftenBthanBusual.”
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