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M ZHESIZexit
HESI RN EXIT
EXAM 2022 V3
Z Z
160 Q&A
Z
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,3/6/24,Z9:13ZP HESIZRNZEXITZEXAMZV3Z-
M ZHESIZexit
1. AZmaleZclientZwithZstomachZcancerZreturnsZtoZtheZunitZfollowingZaZtotalZgastrectomy.ZHeZ
hasZaZnasogastricZtubeZtoZsuctionZandZisZreceivingZLactatedZRinger’sZsolutionZatZ75ZmL/hou
rZIV.ZOneZhourZafterZadmissionZtoZtheZunit,ZtheZnurseZnotesZ300ZmLZofZbloodZinZtheZsucti
onZcanister,ZtheZclient’sZheartZrateZisZ155Zbeats/minute,ZandZhisZbloodZpressureZisZ78/48Z
mmHg.ZInZadditionZtoZreportingZtheZfindingZtoZtheZsurgeon.ZWhichZactionZshouldZtheZnurs
eZimplementZfirst?
a. MeasureZandZdocumentZtheZclient’sZurinaryZoutput.
b. RequestZtheZclient’sZreservedZunitZifZpackedZredZbloodZcells.
c. PrepareZ theZ placementZ ofZ aZ centralZ venousZ catheter.
d. IncreaseZtheZinfusionZrateZofZLactatedZRinger’sZsolution.
2. anZadultZmaleZwhoZfellZ20ZfeetZfromZtheZroofZofZthisZhomeZhasZmultipleZinjuries,ZincludingZaZ
rightZpneumothorax.ZChestZtubesZwereZinsertedZinZtheZemergencyZdepartmentZpriorZtoZhisZtr
ansferZtoZtheZintensiveZcareZunitZ(ICU).ZtheZnurseZnotesZthatZtheZsuctionZcontrolZchamberZisZ
bubblingZatZthe
-
Z10ZcmZH2OZmark,ZwithZfluctuationZinZtheZwaterZseal,ZandZoverZtheZpastZhourZ75ZmlZofZbrig
htZredZbloodZisZmeasuredZinZtheZcollectionZchamber.ZWhichZinterventionZshouldZtheZnurseZim
plement?
a. AddZsterileZwaterZtoZtheZsuctionZcontrolZchamber.
b. GiveZbloodZfromZtheZcollectionZchamberZasZautotransfusion
c. ManipulateZbloodZinZtubingZtoZdrainZintoZ chamber.
d. IncreaseZwallZsuctionZtoZeliminateZfluctuationZinZwaterZseal.
3. AZclientZwhoZreceivedZhemodialysisZyesterdayZisZexperiencingZaZbloodZpressureZofZ200/100Z
mmHg,ZheartZrateZ110Zbeats/minute,ZandZrespiratoryZrateZ36Zbreaths/minute.ZTheZclientZisZ
manifestingZshortnessZofZbreath,ZbilateralZ2+ZpedalZedema,ZandZanZ oxygenZsaturationZonZ roo
mZairZofZ89%.ZWhichZactionZshouldZtheZnurseZtakeZfirst?
a. ElevateZtheZfootZofZtheZbed.
b. RestrictZtheZ client’sZ fluid.
c. BeginZsupplementalZoxygen.
d. PrepareZtheZclientZforZhemodialysis.
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4. AZclientZwithZAddison’sZcrisisZisZadmittedZforZtreatmentZwithZadrenalZcorticalZsupplementatio
n.ZBasedZonZtheZclient’sZadmittingZdiagnosis,ZwhichZfindingsZrequireZimmediateZactionZbyZthe
Znurse?Z(SelectZallZthatZapply)
a. HeadacheZandZtremors
b. IrregularZheartZrate
c. SkinZhyperpigmentation
d. PosturalZhypotension
e. PallorZandZdiaphoresis
5. AnZolderZclientZisZadmittedZwithZfluidZvolumeZdeficitZandZdehydration.ZWhichZassessmentZfin
dingZisZtheZbestZindicatorZofZhydrationZthatZtheZnurseZshouldZreportZtoZtheZhealthcareZprovid
er?
a. UrineZspecificZgravityZisZ1.040
b. SystolicZbloodZpressureZdecreasesZ10ZpointsZwhenZstanding.
c. TheZclientZdeniesZbeingZthirsty.
d. SkinZtentingZoccursZwhenZtheZclient’sZforearmZisZpinched.
6. AfterZanZinserviceZaboutZelectronicZhealthZrecordZ(EHR)ZsecurityZandZsafeguardingZcli
entZinformation,ZtheZnurseZ observesZaZcolleagueZgoingZhomeZwithZprintedZcopiesZofZ
clientZinformationZinZaZuniformZpocket.ZWhichZactionZshouldZtheZnurseZtake?
a. FileZaZdetailedZincidentZreportZwithZtheZspecificZhiringZfacility.
b. WarnZtheZcolleagueZthatZtheirZactionsZareZunprofessional.
c. CommentZanonymouslyZaboutZtheZactionZofZ aZstaffZdiscussionZboard.
d. CommunicateZtheZcolleague’sZactionsZtoZtheZunitZchargeZnurse.
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M ZHESIZexit
7. TheZnurseZisZevaluatingZaZtertiaryZpreventionZprogramZ forZclientsZwithZcardiovascularZdis
easeZimplementedZinZaZruralZhealthZclinic.ZWhichZoutcomeZindicateZtheZprogramZisZeffecti
ve?
a. At-riskZclientsZreceivedZanZincreasedZnumberZofZroutineZhealthZscreenings.
b. ClientsZreportedZhavingZ newZconfidenceZinZmakingZhealthyZ foodZchoices.
c. ClientsZwhoZincurredZdiseaseZcomplicationsZpromptlyZreceivedZrehabilitation.
d. ClientZrelapseZrateZofZ30%ZinZaZ5-yearZcommunity-wideZanti-smokingZcampaign.
8. TheZnurseZisZcaringZforZaZclientZwithZchronicZobstructiveZpulmonaryZdiseaseZ(COPD)ZwhoZ
usesZoxygenZatZ2ZL/minuteZperZnasalZcannulaZcontinuously.ZTheZnurseZobservesZthatZtheZ
clientZisZhavingZincreasedZshortnessZofZbreathZwithZrespirationsZatZ23Zbreaths/minute.ZW
hichZactionZshouldZtheZnurseZimplementZfirst?
a. DetermineZifZtheZclientZisZexperiencingZanyZanxiety.
b. AuscultateZtheZclient’sZbilateralZlungZsoundsZandZoxygenZsaturation.
c. NotifyZtheZhealthcareZproviderZaboutZtheZclient’sZdistress.
d. AssessZtheZdeliveryZmechanismZofZtheZoxygenZtank,Ztubing,ZandZcannula.
9. WhichZstatementZbyZaZclientZwhoZisZ24ZhoursZpost-
subtotalZthyroidectomyZrequiresZanZimmediateZinvestigationZbyZtheZnurse?
a. “WhenZIZgetZoutZofZbedZquickly,ZIZfeelZaZlittleZdizzy.”
b. “TheZdressingZoverZmyZincisionZfeelsZlikeZitZisZtooZtight.”
c. “I’mZmostZcomfortableZwhenZtheZheadZofZtheZbedZisZraised.”
d. “ThisZIVZinfusionZmakesZmeZurinateZmoreZoftenZthanZusual.”
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M ZHESIZexit
HESI RN EXIT
EXAM 2022 V3
Z Z
160 Q&A
Z
about:blank 1/37
,3/6/24,Z9:13ZP HESIZRNZEXITZEXAMZV3Z-
M ZHESIZexit
1. AZmaleZclientZwithZstomachZcancerZreturnsZtoZtheZunitZfollowingZaZtotalZgastrectomy.ZHeZ
hasZaZnasogastricZtubeZtoZsuctionZandZisZreceivingZLactatedZRinger’sZsolutionZatZ75ZmL/hou
rZIV.ZOneZhourZafterZadmissionZtoZtheZunit,ZtheZnurseZnotesZ300ZmLZofZbloodZinZtheZsucti
onZcanister,ZtheZclient’sZheartZrateZisZ155Zbeats/minute,ZandZhisZbloodZpressureZisZ78/48Z
mmHg.ZInZadditionZtoZreportingZtheZfindingZtoZtheZsurgeon.ZWhichZactionZshouldZtheZnurs
eZimplementZfirst?
a. MeasureZandZdocumentZtheZclient’sZurinaryZoutput.
b. RequestZtheZclient’sZreservedZunitZifZpackedZredZbloodZcells.
c. PrepareZ theZ placementZ ofZ aZ centralZ venousZ catheter.
d. IncreaseZtheZinfusionZrateZofZLactatedZRinger’sZsolution.
2. anZadultZmaleZwhoZfellZ20ZfeetZfromZtheZroofZofZthisZhomeZhasZmultipleZinjuries,ZincludingZaZ
rightZpneumothorax.ZChestZtubesZwereZinsertedZinZtheZemergencyZdepartmentZpriorZtoZhisZtr
ansferZtoZtheZintensiveZcareZunitZ(ICU).ZtheZnurseZnotesZthatZtheZsuctionZcontrolZchamberZisZ
bubblingZatZthe
-
Z10ZcmZH2OZmark,ZwithZfluctuationZinZtheZwaterZseal,ZandZoverZtheZpastZhourZ75ZmlZofZbrig
htZredZbloodZisZmeasuredZinZtheZcollectionZchamber.ZWhichZinterventionZshouldZtheZnurseZim
plement?
a. AddZsterileZwaterZtoZtheZsuctionZcontrolZchamber.
b. GiveZbloodZfromZtheZcollectionZchamberZasZautotransfusion
c. ManipulateZbloodZinZtubingZtoZdrainZintoZ chamber.
d. IncreaseZwallZsuctionZtoZeliminateZfluctuationZinZwaterZseal.
3. AZclientZwhoZreceivedZhemodialysisZyesterdayZisZexperiencingZaZbloodZpressureZofZ200/100Z
mmHg,ZheartZrateZ110Zbeats/minute,ZandZrespiratoryZrateZ36Zbreaths/minute.ZTheZclientZisZ
manifestingZshortnessZofZbreath,ZbilateralZ2+ZpedalZedema,ZandZanZ oxygenZsaturationZonZ roo
mZairZofZ89%.ZWhichZactionZshouldZtheZnurseZtakeZfirst?
a. ElevateZtheZfootZofZtheZbed.
b. RestrictZtheZ client’sZ fluid.
c. BeginZsupplementalZoxygen.
d. PrepareZtheZclientZforZhemodialysis.
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4. AZclientZwithZAddison’sZcrisisZisZadmittedZforZtreatmentZwithZadrenalZcorticalZsupplementatio
n.ZBasedZonZtheZclient’sZadmittingZdiagnosis,ZwhichZfindingsZrequireZimmediateZactionZbyZthe
Znurse?Z(SelectZallZthatZapply)
a. HeadacheZandZtremors
b. IrregularZheartZrate
c. SkinZhyperpigmentation
d. PosturalZhypotension
e. PallorZandZdiaphoresis
5. AnZolderZclientZisZadmittedZwithZfluidZvolumeZdeficitZandZdehydration.ZWhichZassessmentZfin
dingZisZtheZbestZindicatorZofZhydrationZthatZtheZnurseZshouldZreportZtoZtheZhealthcareZprovid
er?
a. UrineZspecificZgravityZisZ1.040
b. SystolicZbloodZpressureZdecreasesZ10ZpointsZwhenZstanding.
c. TheZclientZdeniesZbeingZthirsty.
d. SkinZtentingZoccursZwhenZtheZclient’sZforearmZisZpinched.
6. AfterZanZinserviceZaboutZelectronicZhealthZrecordZ(EHR)ZsecurityZandZsafeguardingZcli
entZinformation,ZtheZnurseZ observesZaZcolleagueZgoingZhomeZwithZprintedZcopiesZofZ
clientZinformationZinZaZuniformZpocket.ZWhichZactionZshouldZtheZnurseZtake?
a. FileZaZdetailedZincidentZreportZwithZtheZspecificZhiringZfacility.
b. WarnZtheZcolleagueZthatZtheirZactionsZareZunprofessional.
c. CommentZanonymouslyZaboutZtheZactionZofZ aZstaffZdiscussionZboard.
d. CommunicateZtheZcolleague’sZactionsZtoZtheZunitZchargeZnurse.
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M ZHESIZexit
7. TheZnurseZisZevaluatingZaZtertiaryZpreventionZprogramZ forZclientsZwithZcardiovascularZdis
easeZimplementedZinZaZruralZhealthZclinic.ZWhichZoutcomeZindicateZtheZprogramZisZeffecti
ve?
a. At-riskZclientsZreceivedZanZincreasedZnumberZofZroutineZhealthZscreenings.
b. ClientsZreportedZhavingZ newZconfidenceZinZmakingZhealthyZ foodZchoices.
c. ClientsZwhoZincurredZdiseaseZcomplicationsZpromptlyZreceivedZrehabilitation.
d. ClientZrelapseZrateZofZ30%ZinZaZ5-yearZcommunity-wideZanti-smokingZcampaign.
8. TheZnurseZisZcaringZforZaZclientZwithZchronicZobstructiveZpulmonaryZdiseaseZ(COPD)ZwhoZ
usesZoxygenZatZ2ZL/minuteZperZnasalZcannulaZcontinuously.ZTheZnurseZobservesZthatZtheZ
clientZisZhavingZincreasedZshortnessZofZbreathZwithZrespirationsZatZ23Zbreaths/minute.ZW
hichZactionZshouldZtheZnurseZimplementZfirst?
a. DetermineZifZtheZclientZisZexperiencingZanyZanxiety.
b. AuscultateZtheZclient’sZbilateralZlungZsoundsZandZoxygenZsaturation.
c. NotifyZtheZhealthcareZproviderZaboutZtheZclient’sZdistress.
d. AssessZtheZdeliveryZmechanismZofZtheZoxygenZtank,Ztubing,ZandZcannula.
9. WhichZstatementZbyZaZclientZwhoZisZ24ZhoursZpost-
subtotalZthyroidectomyZrequiresZanZimmediateZinvestigationZbyZtheZnurse?
a. “WhenZIZgetZoutZofZbedZquickly,ZIZfeelZaZlittleZdizzy.”
b. “TheZdressingZoverZmyZincisionZfeelsZlikeZitZisZtooZtight.”
c. “I’mZmostZcomfortableZwhenZtheZheadZofZtheZbedZisZraised.”
d. “ThisZIVZinfusionZmakesZmeZurinateZmoreZoftenZthanZusual.”
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