ne
tz
sh
ne
HESI EXIT V5 160Q (Answered) Verified Answers
la
tz
sh
Suicide precautions are initiated for a child admitted to the mental health unit following
Sp
ne
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
la
implement?
tz
sh
{correct ans} Remove cigarettes for the client's room
Sp
ne
A family member of a frail elderly adult asks the nurse about eligibility requirements for
la
hospice care. What information should the nurse provide? (Select all that apply.)
tz
sh
Sp
A.)A client must be willing to accept palliative care, not curative care.
ne
la
B.)The healthcare provider must project that the client has 6 months or less to live.
tz
sh
Sp
C.)The client must be diagnosed with clinical depression
ne
la
D.)The client must be of sound mind
tz
{correct ans} A,B
sh
Sp
ne
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction
la
should the nurse include in this client's teaching plan?
tz
{correct ans} Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
sh
Sp
ne
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is
la
irritable and diaphoretic with jugular vein distention. Which prescription should the nurse
tz
administer first?
sh
Sp
{correct ans} Digoxin
ne
la
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse
tz
(PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse
sh
Sp
assign to the RN?
ne
{correct ans} Supervise a newly hired graduate nurse during an admission assessment.
la
tz
While teaching a young male adult to use an inhaler for his newly diagnosed asthma,
sh
Sp
the client stares into the distance and appears to be concentrating on something other
ne
than the lesson the nurse is presenting. What action should the nurse take?
{correct ans} Ask the client what he is thinking about at his time.
la
tz
sh
After several hours of non-productive coughing, a client presents to the emergency
Sp
ne
room complaining of chest tightness and shortness of breath. History includes end
stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While
la
completing the pulmonary assessment, the nurse hears wheezing and poor air
tz
sh
movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
Sp
ne
A.)Administer PRN nebulizer treatment.
la
sh
Sp
la
Sp
, ne
tz
sh
ne
B.)Obtain 12 lead electrocardiogram.
la
tz
sh
Sp
C.)Monitor continuous oxygen saturation.
ne
D.) Lay the client in the prone position
la
tz
{correct ans} A,B,C
sh
Sp
ne
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.
la
tz
What action should the nurse take?
sh
{correct ans} Administer a prescribed analgesia for pain.
Sp
ne
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT)
la
protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which
tz
sh
information should the nurse provide the parents about caring for their child?
Sp
{correct ans} Use sunblock or protective clothing when outdoors.
ne
la
Two days after admission a male client remembers that he is allergic to eggs, and
tz
sh
informs the nurse of the allergy. Which actions should the nurse implement? SATA
Sp
ne
A.) Tell the client that its a mild reaction
la
tz
sh
B.)Notify the food services department of the allergy.
Sp
ne
C.)Enter the allergy information in the client's record.
la
tz
D.)Add egg allergy to the client's allergy arm band.
sh
Sp
{correct ans} B,C,D
ne
la
The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min
tz
of continuous chest compressions. The client has a weak, fast pulse and no respiratory
sh
Sp
effort, so the healthcare provider performs a successful oral, intubation. What action
ne
should the nurse implement?
la
{correct ans} Perform bilateral chest auscultation.
tz
sh
Sp
After administering an antipyretic medication. Which intervention should the nurse
ne
implement?
la
{correct ans} Encouraging liberal fluid intake
tz
sh
Sp
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which
ne
explanation should be included in preparing this client for this treatment?
la
{correct ans} Describe radioactive iodine as a tasteless, colorless medication
tz
administered by the healthcare provider
sh
Sp
ne
la
sh
Sp
la
Sp
, ne
tz
sh
ne
After a colon resection for colon cancer, a male client is moaning while being
la
transferred to the Postanesthesia Care Unit (PACU). Which intervention should the
tz
nurse implement first?
sh
Sp
{correct ans} Determine client's pulse, blood pressure, and respirations
ne
la
The nurse is caring for a group of clients with the help of a licensed practical nurse
tz
(LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures
sh
Sp
can the nurse delegate to the UAP? (Select all that apply)
ne
A.)Take postoperative vital signs for a client who has an epidual following knee
la
tz
arthroplasty
sh
Sp
ne
B.)Collect a sputum specimen for a client with a fever of unknown origin
la
C.)Ambulate a client who had a femoral-popliteal bypass graft yesterday
tz
sh
{correct ans} A,B,C
Sp
ne
A male client with cirrhosis has ascites and reports feeling short of breath. The client is
la
in semi Fowler position with his arms at his side. What action should the nurse
tz
sh
implement?
Sp
{correct ans} Raise the head of the bed to a Fowler's position and support his arms with
ne
a pillow
la
tz
sh
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert
Sp
but has difficulty describing the exact nature and location of the pain to the nurse. Which
ne
action should the nurse implement next?
la
{correct ans} Administer the analgesic as requested
tz
sh
Sp
The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid
ne
replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns
la
who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)
{correct ans} 12160
tz
sh
Sp
ne
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values
la
indicate the client has thrombocytopenia. Based on this data, which nursing assessment
tz
is most important following the procedure?
sh
Sp
ne
A.)Observe aspiration site.
la
tz
B.)Assess body temperature
sh
Sp
ne
C.)Monitor skin elasticity
la
tz
D.)Measure urinary output
sh
Sp
{correct ans} A
ne
la
sh
Sp
la
Sp
, ne
tz
sh
ne
An 18-year-old female client is seen at the health department for treatment of
la
condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV).
tz
Which intervention should the nurse implement?
sh
Sp
{correct ans} Reinforce the importance of annual papanicolaou (Pap) smears.
ne
la
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep
tz
during the day, refuses to take a bath, and refuses to eat. Which nursing intervention
sh
Sp
should the nurse implement first?
ne
{correct ans} Establish a structured routine for the client to follow.
la
tz
A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse,
sh
and hypotension. Which assessment finding warrants immediate intervention by the
Sp
ne
nurse?
{correct ans} Ventricular arrhythmias.
la
tz
sh
The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper
Sp
ne
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?
la
{correct ans} Instruct the mother to change the child's diaper more often.
tz
sh
Sp
A resident of a long-term care facility, who has moderate dementia, is having difficulty
ne
eating in the dining room. The client becomes frustrated when dropping utensils on the
la
floor and then refuses to eat. What action should the nurse implement?
tz
sh
{correct ans} Encourage the client to eat finger foods.
Sp
ne
A client is receiving mesalamine 800 mg PO TID. Which assessment is most important
la
for the nurse to perform to assess the effectiveness of the medication?
tz
{correct ans} Bowel patterns
sh
Sp
ne
While in the medical records department, the nurse observes several old medical
la
records with names visible in waste container. What action should the nurse
implement?
tz
sh
Sp
{correct ans} Contact the medical records department supervisor.
ne
la
A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV
tz
infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters
sh
Sp
of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal
ne
saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric
la
value only. If rounding is required, round to the nearest whole number.)
tz
{correct ans} 83
sh
Sp
ne
While visiting a female client who has heart failure (HF) and osteoarthritis, the home
la
health nurse determines that the client is having more difficulty getting in and out of the
tz
bed than she did previously. Which action should the nurse implement first?
sh
Sp
{correct ans} Submit a referral for an evaluation by a physical therapist.
ne
la
sh
Sp
la
Sp
tz
sh
ne
HESI EXIT V5 160Q (Answered) Verified Answers
la
tz
sh
Suicide precautions are initiated for a child admitted to the mental health unit following
Sp
ne
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
la
implement?
tz
sh
{correct ans} Remove cigarettes for the client's room
Sp
ne
A family member of a frail elderly adult asks the nurse about eligibility requirements for
la
hospice care. What information should the nurse provide? (Select all that apply.)
tz
sh
Sp
A.)A client must be willing to accept palliative care, not curative care.
ne
la
B.)The healthcare provider must project that the client has 6 months or less to live.
tz
sh
Sp
C.)The client must be diagnosed with clinical depression
ne
la
D.)The client must be of sound mind
tz
{correct ans} A,B
sh
Sp
ne
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction
la
should the nurse include in this client's teaching plan?
tz
{correct ans} Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
sh
Sp
ne
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is
la
irritable and diaphoretic with jugular vein distention. Which prescription should the nurse
tz
administer first?
sh
Sp
{correct ans} Digoxin
ne
la
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse
tz
(PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse
sh
Sp
assign to the RN?
ne
{correct ans} Supervise a newly hired graduate nurse during an admission assessment.
la
tz
While teaching a young male adult to use an inhaler for his newly diagnosed asthma,
sh
Sp
the client stares into the distance and appears to be concentrating on something other
ne
than the lesson the nurse is presenting. What action should the nurse take?
{correct ans} Ask the client what he is thinking about at his time.
la
tz
sh
After several hours of non-productive coughing, a client presents to the emergency
Sp
ne
room complaining of chest tightness and shortness of breath. History includes end
stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While
la
completing the pulmonary assessment, the nurse hears wheezing and poor air
tz
sh
movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
Sp
ne
A.)Administer PRN nebulizer treatment.
la
sh
Sp
la
Sp
, ne
tz
sh
ne
B.)Obtain 12 lead electrocardiogram.
la
tz
sh
Sp
C.)Monitor continuous oxygen saturation.
ne
D.) Lay the client in the prone position
la
tz
{correct ans} A,B,C
sh
Sp
ne
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.
la
tz
What action should the nurse take?
sh
{correct ans} Administer a prescribed analgesia for pain.
Sp
ne
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT)
la
protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which
tz
sh
information should the nurse provide the parents about caring for their child?
Sp
{correct ans} Use sunblock or protective clothing when outdoors.
ne
la
Two days after admission a male client remembers that he is allergic to eggs, and
tz
sh
informs the nurse of the allergy. Which actions should the nurse implement? SATA
Sp
ne
A.) Tell the client that its a mild reaction
la
tz
sh
B.)Notify the food services department of the allergy.
Sp
ne
C.)Enter the allergy information in the client's record.
la
tz
D.)Add egg allergy to the client's allergy arm band.
sh
Sp
{correct ans} B,C,D
ne
la
The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min
tz
of continuous chest compressions. The client has a weak, fast pulse and no respiratory
sh
Sp
effort, so the healthcare provider performs a successful oral, intubation. What action
ne
should the nurse implement?
la
{correct ans} Perform bilateral chest auscultation.
tz
sh
Sp
After administering an antipyretic medication. Which intervention should the nurse
ne
implement?
la
{correct ans} Encouraging liberal fluid intake
tz
sh
Sp
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which
ne
explanation should be included in preparing this client for this treatment?
la
{correct ans} Describe radioactive iodine as a tasteless, colorless medication
tz
administered by the healthcare provider
sh
Sp
ne
la
sh
Sp
la
Sp
, ne
tz
sh
ne
After a colon resection for colon cancer, a male client is moaning while being
la
transferred to the Postanesthesia Care Unit (PACU). Which intervention should the
tz
nurse implement first?
sh
Sp
{correct ans} Determine client's pulse, blood pressure, and respirations
ne
la
The nurse is caring for a group of clients with the help of a licensed practical nurse
tz
(LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures
sh
Sp
can the nurse delegate to the UAP? (Select all that apply)
ne
A.)Take postoperative vital signs for a client who has an epidual following knee
la
tz
arthroplasty
sh
Sp
ne
B.)Collect a sputum specimen for a client with a fever of unknown origin
la
C.)Ambulate a client who had a femoral-popliteal bypass graft yesterday
tz
sh
{correct ans} A,B,C
Sp
ne
A male client with cirrhosis has ascites and reports feeling short of breath. The client is
la
in semi Fowler position with his arms at his side. What action should the nurse
tz
sh
implement?
Sp
{correct ans} Raise the head of the bed to a Fowler's position and support his arms with
ne
a pillow
la
tz
sh
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert
Sp
but has difficulty describing the exact nature and location of the pain to the nurse. Which
ne
action should the nurse implement next?
la
{correct ans} Administer the analgesic as requested
tz
sh
Sp
The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid
ne
replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns
la
who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)
{correct ans} 12160
tz
sh
Sp
ne
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values
la
indicate the client has thrombocytopenia. Based on this data, which nursing assessment
tz
is most important following the procedure?
sh
Sp
ne
A.)Observe aspiration site.
la
tz
B.)Assess body temperature
sh
Sp
ne
C.)Monitor skin elasticity
la
tz
D.)Measure urinary output
sh
Sp
{correct ans} A
ne
la
sh
Sp
la
Sp
, ne
tz
sh
ne
An 18-year-old female client is seen at the health department for treatment of
la
condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV).
tz
Which intervention should the nurse implement?
sh
Sp
{correct ans} Reinforce the importance of annual papanicolaou (Pap) smears.
ne
la
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep
tz
during the day, refuses to take a bath, and refuses to eat. Which nursing intervention
sh
Sp
should the nurse implement first?
ne
{correct ans} Establish a structured routine for the client to follow.
la
tz
A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse,
sh
and hypotension. Which assessment finding warrants immediate intervention by the
Sp
ne
nurse?
{correct ans} Ventricular arrhythmias.
la
tz
sh
The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper
Sp
ne
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?
la
{correct ans} Instruct the mother to change the child's diaper more often.
tz
sh
Sp
A resident of a long-term care facility, who has moderate dementia, is having difficulty
ne
eating in the dining room. The client becomes frustrated when dropping utensils on the
la
floor and then refuses to eat. What action should the nurse implement?
tz
sh
{correct ans} Encourage the client to eat finger foods.
Sp
ne
A client is receiving mesalamine 800 mg PO TID. Which assessment is most important
la
for the nurse to perform to assess the effectiveness of the medication?
tz
{correct ans} Bowel patterns
sh
Sp
ne
While in the medical records department, the nurse observes several old medical
la
records with names visible in waste container. What action should the nurse
implement?
tz
sh
Sp
{correct ans} Contact the medical records department supervisor.
ne
la
A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV
tz
infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters
sh
Sp
of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal
ne
saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric
la
value only. If rounding is required, round to the nearest whole number.)
tz
{correct ans} 83
sh
Sp
ne
While visiting a female client who has heart failure (HF) and osteoarthritis, the home
la
health nurse determines that the client is having more difficulty getting in and out of the
tz
bed than she did previously. Which action should the nurse implement first?
sh
Sp
{correct ans} Submit a referral for an evaluation by a physical therapist.
ne
la
sh
Sp
la
Sp
