3/29/25, 8:27 V3 exit HESI Flashcards |
AM
V3 EXIT HESI EXAM QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS
VERIFIED GRADED A++
Terms in this set (124)
Which assessment should the home health Observe insertion site
nurse include during a routine home visit
for a client who was discharged home with
a colostomy bag?
A client with arthritis has been receiving Hemoglobin
treatment with naproxen and now reports
ongoing stomach pain, increasing
weakness and fatigue. Which lab test
should the nurse monitor?
A client with influenza needs help in Review the need for the UAP to wear a face mask while in close contact with the
transferring to the bedside commode. The client.
nurse observes the unlicensed assistive
personnel (UAP) donning gloves and a
gown to assist the client. Which action
should the nurse take?
A client is receiving lactulose for signs of Serum electrolytes.
hepatic encephalopathy. To evaluate
the client's therapeutic response to
this
medication, which assessment should the
nurse obtain?
A mother calls the nurse to report that at Withhold this dose.
0900 she administered an oral dose of
digoxin to her 4-month-old infant, but at
0920 the baby vomited the medicine.
Which instruction should the nurse provide
to this mother?
1/16
,3/29/25, 8:27 V3 exit HESI Flashcards |
AM
The nurse is providing education to a Practice using muscle relaxation techniques.
client who experiences recurrent levels
of
moderate anxiety to situations and
perceived stress. In addition to
information about prescribed
medication and
administration, which instruction should the
nurse include in the teaching?
The lower limit for normal plasma glucose Normal findings include acrocyanosis, soft fontanelles, Mongolian spots, and Apgar
levels during the first 72 hours after birth scores of 7 to 10.
is 40 to 45 mg/dL (2.2 to 2.5 mmol/L).
Hypoglycemia is most common in the
macrocosmic or LGA infant, but the nurse
should monitor blood glucose levels in all
infants of mothers with known or suspected
diabetes. Hypoglycemia most frequently
occurs within the first 1 to 6 hours after
birth. Signs of hypoglycemia include
jitteriness, apnea, tachypnea, hypotonia,
decreased activity, and cyanosis. A
Ballard score maturity assessment of
37
corresponds to 37 weeks gestation, which
is a early term. Early term (37 0/7 through
38 6/7 weeks). Compared with full-term
infants, early-term infants are at increased
risk for morbidity and mortality.
The nurse is reviewing the possible The nurse recognizes that the infant of a diabetic mother is at risk for
complications that can occur for an infant hyperbilirubinemia, respiratory distress syndrome, and cardiomyopathy
of a diabetic mother. Choose the most
likely options for the information missing
from the statement(s) by selecting from the
lists of options provided.
Glucose level immediately after birth Monitor for Respiratory distress, contact respiratory therapy for ABG and oxygen
and then at 30 min, 1 hour, 2 hours, 4 therapy, blood glucose level, keep in warmer with Bilirubin lights, monitor
hours, 8 and 12 hours and if symptoms temperature every 30 minutes, feed immediately
suggest
hypoglycemla.
• Breastfeed Immediately once
stable, then on
demand. If unstable, may feed breast milk
via
orogastric tube.
• If two feeding attempts fall to
increase the glucose levels or if
symptoms of
hypoglycemia
develop, apply dextrose (sugar) gel Inside
the
baby's cheek.
• If the above are ineffective,
IV glucose should
be administered to maintain glucose levels
above 45 mg/dL (2.5 mmol/L).
2/16
, 3/29/25, 8:27 V3 exit HESI Flashcards |
AM
The nurse is reviewing lab work and nurses' A Keep infant In warmer with bilirubin lights to maintain temperature of 97.6°
notes to determine which actions to B Inform the mother that the baby is stable enough to take out of the warmer
take at this time. Which actions are D Explain to the mother that the baby's respiratory rate needs to be below 60 1
appropriate for the nurse to take at E Observe for signs of respiratory distress and monitor oxygenation by pulse c
this time? Select all that apply.
Day 1 Proactive lactation management, strategies, support, and follow-up for late-preterm
1800: The client Is a female neonate born at infants and some early term infants are important components that affect
37 weeks of gestation to a G 2 P 1 breastfeeding success. Prophylactic phototherapy is often used in preterm infants to
mother, who was diagnosed with prevent a significant increase in serum bilirubin levels. It is also recommended that
gestational healthy late-preterm and term infants (23S weeks of gestation) receive follow-up
dlabetes. Following a spontaneous vaginal care and assessment of bilirubin within 3 days of discharge. Late preterm infants of
birth, she received Apgar scores of 7 at a diabetic mother need to be monitored more closely. Parents are taught to evaluate
1 min and 8 at 5 min. The client weighs the number of voids and evidence of adequate breastfeeding after the infant is
4036.97 g (8 Ibs. 9 oz) and appears pink home. Notify the primary care practitioner if there are indications the infant is not
with acrocyanosis and a moderate amount feeding well, is difficult to arouse for feedings, or is not voiding and stooling
of subcutaneous fat. She is noted to be adequately. Seeing the obstetrician at 8 weeks is contraindicated, as most
slightly jittery at 30 min of age. Axillary postpartum visits are between 4 and 6 wecks. ACOG recommends that postpartum
temperature 96° F (35.6° C), pulse 140, care be an ongoing process in which each woman's individual needs determine the
respiratory rate 80. Blood glucose 35 services and support she receives. Early follow-up is warranted for women
mg/dL (1.9 mmol/L), bilirubin level 7 mg/dL who
(119.73 umol/L). Fontanelles soft, Mongolian experienced complications such as hypertensive disorders of pregnancy, those with
spot noted on lower back, Ballard maturity chronic health conditions, women at high risk for depression, and breastfeeding
rating 37 weeks. mothers who are experiencing feeding problems,
Click to highlight the notes Studies confirm the importance of maintaining serum glucose levels above 45 mg/dL
that demonstrate a positive (25 mmol/1) in hyper insulinemic infants with hypoglycemia to prevent serious
outcome. Day 2 neurologic sequel. Blood glucose levels continue to improve. Direct bilirubin
0630: Vitals have remained stable improved. Other signs of improvement include a normal temperature for at least 8
throughout the night. Oxygen 98% on nasal hours, improved respiratory status with no signs of respiratory distress syndrome and
canal. Mother to breastfeed in nursery feedings are well tolerated.
on demand. Able to tolerate breastmilk.
Glucose after feeding was 60 mg/dL (3.3
mmol/L), temp 97.8° F (36.6° C) when
returned to warmer and Bili light. Chest x-
ray and echocardiogram results were
normal. Calcium and magnesium within
normal llmits, Direct bilirubin 5 mg/dI(5
umol/L), Discharge teaching Initlated, with
goal of discharging infant and mother
on day 3.
Eat approximately the same amount of leafy green vegetables daily so the amount
of vitamin K consumed is consistent.
A client is being discharged with a
prescription for warfarin. Which instruction
should the nurse provide this client -The warfarin dose is prescribed and adjusted based on the client's normal
regarding diet? consumption of foods containingvitamin K (an essential clotting factor that
counteracts the effects of warfarin), so the client should eat a consistent amount of
vitamin K food sources on a daily basis.
The nurse is planning care for a client who Begins to show signs of Improvement in affect.
admits having suicidal thoughts. Which
client behaviour indicates the highest
risk for the client acting on these
suicidal thoughts?
3/16
AM
V3 EXIT HESI EXAM QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS
VERIFIED GRADED A++
Terms in this set (124)
Which assessment should the home health Observe insertion site
nurse include during a routine home visit
for a client who was discharged home with
a colostomy bag?
A client with arthritis has been receiving Hemoglobin
treatment with naproxen and now reports
ongoing stomach pain, increasing
weakness and fatigue. Which lab test
should the nurse monitor?
A client with influenza needs help in Review the need for the UAP to wear a face mask while in close contact with the
transferring to the bedside commode. The client.
nurse observes the unlicensed assistive
personnel (UAP) donning gloves and a
gown to assist the client. Which action
should the nurse take?
A client is receiving lactulose for signs of Serum electrolytes.
hepatic encephalopathy. To evaluate
the client's therapeutic response to
this
medication, which assessment should the
nurse obtain?
A mother calls the nurse to report that at Withhold this dose.
0900 she administered an oral dose of
digoxin to her 4-month-old infant, but at
0920 the baby vomited the medicine.
Which instruction should the nurse provide
to this mother?
1/16
,3/29/25, 8:27 V3 exit HESI Flashcards |
AM
The nurse is providing education to a Practice using muscle relaxation techniques.
client who experiences recurrent levels
of
moderate anxiety to situations and
perceived stress. In addition to
information about prescribed
medication and
administration, which instruction should the
nurse include in the teaching?
The lower limit for normal plasma glucose Normal findings include acrocyanosis, soft fontanelles, Mongolian spots, and Apgar
levels during the first 72 hours after birth scores of 7 to 10.
is 40 to 45 mg/dL (2.2 to 2.5 mmol/L).
Hypoglycemia is most common in the
macrocosmic or LGA infant, but the nurse
should monitor blood glucose levels in all
infants of mothers with known or suspected
diabetes. Hypoglycemia most frequently
occurs within the first 1 to 6 hours after
birth. Signs of hypoglycemia include
jitteriness, apnea, tachypnea, hypotonia,
decreased activity, and cyanosis. A
Ballard score maturity assessment of
37
corresponds to 37 weeks gestation, which
is a early term. Early term (37 0/7 through
38 6/7 weeks). Compared with full-term
infants, early-term infants are at increased
risk for morbidity and mortality.
The nurse is reviewing the possible The nurse recognizes that the infant of a diabetic mother is at risk for
complications that can occur for an infant hyperbilirubinemia, respiratory distress syndrome, and cardiomyopathy
of a diabetic mother. Choose the most
likely options for the information missing
from the statement(s) by selecting from the
lists of options provided.
Glucose level immediately after birth Monitor for Respiratory distress, contact respiratory therapy for ABG and oxygen
and then at 30 min, 1 hour, 2 hours, 4 therapy, blood glucose level, keep in warmer with Bilirubin lights, monitor
hours, 8 and 12 hours and if symptoms temperature every 30 minutes, feed immediately
suggest
hypoglycemla.
• Breastfeed Immediately once
stable, then on
demand. If unstable, may feed breast milk
via
orogastric tube.
• If two feeding attempts fall to
increase the glucose levels or if
symptoms of
hypoglycemia
develop, apply dextrose (sugar) gel Inside
the
baby's cheek.
• If the above are ineffective,
IV glucose should
be administered to maintain glucose levels
above 45 mg/dL (2.5 mmol/L).
2/16
, 3/29/25, 8:27 V3 exit HESI Flashcards |
AM
The nurse is reviewing lab work and nurses' A Keep infant In warmer with bilirubin lights to maintain temperature of 97.6°
notes to determine which actions to B Inform the mother that the baby is stable enough to take out of the warmer
take at this time. Which actions are D Explain to the mother that the baby's respiratory rate needs to be below 60 1
appropriate for the nurse to take at E Observe for signs of respiratory distress and monitor oxygenation by pulse c
this time? Select all that apply.
Day 1 Proactive lactation management, strategies, support, and follow-up for late-preterm
1800: The client Is a female neonate born at infants and some early term infants are important components that affect
37 weeks of gestation to a G 2 P 1 breastfeeding success. Prophylactic phototherapy is often used in preterm infants to
mother, who was diagnosed with prevent a significant increase in serum bilirubin levels. It is also recommended that
gestational healthy late-preterm and term infants (23S weeks of gestation) receive follow-up
dlabetes. Following a spontaneous vaginal care and assessment of bilirubin within 3 days of discharge. Late preterm infants of
birth, she received Apgar scores of 7 at a diabetic mother need to be monitored more closely. Parents are taught to evaluate
1 min and 8 at 5 min. The client weighs the number of voids and evidence of adequate breastfeeding after the infant is
4036.97 g (8 Ibs. 9 oz) and appears pink home. Notify the primary care practitioner if there are indications the infant is not
with acrocyanosis and a moderate amount feeding well, is difficult to arouse for feedings, or is not voiding and stooling
of subcutaneous fat. She is noted to be adequately. Seeing the obstetrician at 8 weeks is contraindicated, as most
slightly jittery at 30 min of age. Axillary postpartum visits are between 4 and 6 wecks. ACOG recommends that postpartum
temperature 96° F (35.6° C), pulse 140, care be an ongoing process in which each woman's individual needs determine the
respiratory rate 80. Blood glucose 35 services and support she receives. Early follow-up is warranted for women
mg/dL (1.9 mmol/L), bilirubin level 7 mg/dL who
(119.73 umol/L). Fontanelles soft, Mongolian experienced complications such as hypertensive disorders of pregnancy, those with
spot noted on lower back, Ballard maturity chronic health conditions, women at high risk for depression, and breastfeeding
rating 37 weeks. mothers who are experiencing feeding problems,
Click to highlight the notes Studies confirm the importance of maintaining serum glucose levels above 45 mg/dL
that demonstrate a positive (25 mmol/1) in hyper insulinemic infants with hypoglycemia to prevent serious
outcome. Day 2 neurologic sequel. Blood glucose levels continue to improve. Direct bilirubin
0630: Vitals have remained stable improved. Other signs of improvement include a normal temperature for at least 8
throughout the night. Oxygen 98% on nasal hours, improved respiratory status with no signs of respiratory distress syndrome and
canal. Mother to breastfeed in nursery feedings are well tolerated.
on demand. Able to tolerate breastmilk.
Glucose after feeding was 60 mg/dL (3.3
mmol/L), temp 97.8° F (36.6° C) when
returned to warmer and Bili light. Chest x-
ray and echocardiogram results were
normal. Calcium and magnesium within
normal llmits, Direct bilirubin 5 mg/dI(5
umol/L), Discharge teaching Initlated, with
goal of discharging infant and mother
on day 3.
Eat approximately the same amount of leafy green vegetables daily so the amount
of vitamin K consumed is consistent.
A client is being discharged with a
prescription for warfarin. Which instruction
should the nurse provide this client -The warfarin dose is prescribed and adjusted based on the client's normal
regarding diet? consumption of foods containingvitamin K (an essential clotting factor that
counteracts the effects of warfarin), so the client should eat a consistent amount of
vitamin K food sources on a daily basis.
The nurse is planning care for a client who Begins to show signs of Improvement in affect.
admits having suicidal thoughts. Which
client behaviour indicates the highest
risk for the client acting on these
suicidal thoughts?
3/16
