ne
tz
sh
ne
PN Hesi Exit V4 la
tz
An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions.
sh
Sp
When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical
ne
manifestation does the nurse expect to find if nacy's sysmptoms have been caused by a brain attack
la
(stroke)?
tz
A. A carotid bruit
sh
B. A hypotensive blood pressure
Sp
ne
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds Correct Answer: a
la
tz
sh
Which clinical manifestation further supports an assessment of a left-sided brain attack?
Sp
A) Visual field deficit on the left side.
ne
B) Spatial-perceptual deficits.
la
C) Paresthesia of the left side.
tz
sh
D) Global aphasia. Correct Answer: D
Sp
ne
When preparing a patient for a noncontrast computed tomography (CT) scan STAT, what nursing
la
intervention should the nurse implement?
tz
A) Determine if the client has any allergies to iodine
sh
Sp
B) Explain that the client will not be able to move her head throughout the CT scan.
ne
C) Premedicate the client to decrease pain prior to having the procedure.
la
D) Provide an explanation of relaxation exercises prior to the procedure. Correct Answer: B
tz
sh
Sp
A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a patient. Which data
ne
warrants immediate intervention by the nurse concerning this diagnostic test?
A) Elevated blood pressure.
la
tz
B) Allergy to shell fish. sh
C) Right hip replacement.
Sp
ne
D) History of atrial fibrillation. Correct Answer: C
la
A client's daughter is sitting by her mother's bedside who was recently transferred to the Intermediate
tz
sh
Care Unit. She states "I don't understand what a brain attack is. The healthcare provider told me my
Sp
mother is in serious condition and they are going to run several tests. I just don't know what is going on.
ne
What happened to my mother?" What is the best response by the nurse?
la
A) "I am sorry, but according to the Health Insurance Portability and Accounting Act (HIPAA), I cannot
tz
give you any information."
sh
Sp
B) "Your mother has had a stroke, and the blood supply to the brain has been blocked."
ne
C) "How do you feel about what the healthcare provider said?"
la
D) "I will call the healthcare provider so he/she can talk to you about your mother's serious condition."
tz
Correct Answer: B
sh
Sp
ne
What is the normal range for cardiac output? Correct Answer: 4-8L/min
la
tz
A client was admitted with the diagnosis of a brain attack. Their symptoms began 24 hours before being
sh
Sp
admitted. Why would this client not be a candidate for for thrombolytic therapy? Correct Answer:
ne
Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to
admission. This client had symptoms for 24 hours before being brought to the medical center
la
sh
Sp
la
Sp
, ne
tz
sh
ne
la
What are plate guards? Correct Answer: Plate guards prevent food from being pushed off the plate.
tz
Using plate guards and other assistive devices will encourage independence in a client with a self-care
sh
Sp
deficit.
ne
Which condition is considered a non-modifiable risk factor for a brain attack?
la
A) High cholesterol levels.
tz
sh
B) Obesity.
Sp
C) History of atrial fibrillation.
ne
D) Advanced age. Correct Answer: D
la
tz
sh
A client is experiencing homonymous hemianopsia as the result of a brain attack. Which nursing
Sp
intervention would the nurse implement to address this condition?
ne
A) Turn Nancy every two hours and perform active range of motion exercises.
la
B) Place the objects Nancy needs for activities of daily living on the left side of the table.
tz
C) Speak slowly and clearly to assist Nancy in forming sounds to words.
sh
Sp
D) Request that the dietary department thicken all liquids on Nancy's meal and snack trays. Correct
ne
Answer: B
la
tz
A physical therapist (PT) places a gait belt on a client and is assisting them with ambulation from the bed
sh
Sp
to the chair. As they get up out of the bed, they report being dizzy and begin to fall. The PT carefully
ne
allows them to fall back to the bed and notifies the primary nurse. Which written documentation should
la
the nurse put in the client's record?
tz
A) Client experienced orthostatic hypotension when getting out of bed.
sh
B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow
Sp
ne
client to fall back onto the bed.
C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness.
la
D) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance
tz
report completed. Correct Answer: B
sh
Sp
ne
A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs):
la
pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of
tz
sh
these actions by the new graduate is indicated?
Sp
A) Encourage the client to use the incentive spirometer and to cough.
ne
B) Administer oxygen by nasal cannula.
la
C) Request a prescription for sodium bicarbonate from the health care provider.
tz
D) Inform the charge nurse that no changes in therapy are needed. Correct Answer: A
sh
Sp
ne
The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of
la
coronary heart disease (CHD). Which information should the nurse include?
tz
A) Limit dietary selection of cholesterol to 300 mg per day
sh
Sp
B) Increase intake of soluble fiber to 10 to 25 grams per day.
ne
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake. Correct Answer: B
la
tz
sh
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the
Sp
ne
nurse provides the most accurate explanation for use of the splints?
A) Prevention of deformities.
la
sh
Sp
la
Sp
, ne
tz
sh
ne
B) Avoidance of joint trauma.
la
C) Relief of joint inflammation.
tz
D) Improvement in joint strength. Correct Answer: A
sh
Sp
ne
A 32-year-old female client complains of severe abdominal pain each month before her menstrual
period, painful intercourse, and painful defecation. Which additional history should the nurse obtain
la
that is consistent with the client's complaints?
tz
sh
A) Frequent urinary tract infections.
Sp
B) Inability to get pregnant.
ne
C) Premenstrual syndrome.
la
D) Chronic use of laxatives. Correct Answer: B
tz
sh
Sp
A client with a 16-year history of diabetes mellitus is having renal function tests because of recent
ne
fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the
la
nurse conclude as an early symptom of renal insufficiency?
tz
A) Dyspnea.
sh
Sp
B) Nocturia.
ne
C) Confusion.
la
D) Stomatitis. Correct Answer: B
tz
sh
Sp
A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In
ne
determining the possible cause of the bradycardia, the nurse assesses the client's medication record.
la
Which medication is most likely the cause of the bradycardia?
tz
A) Propanolol (Inderal).
sh
B) Captopril (Capoten).
Sp
ne
C) Furosemide (Lasix).
D) Dobutamine (Dobutrex). Correct Answer: A
la
tz
sh
A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which
Sp
assessment finding is of most concern to the nurse?
ne
A) White blood count of 10,000 mm3.
la
B) Serum glucose of 115 mg/dl.
tz
sh
C) Purulent sputum.
Sp
D) Excessive hunger. Correct Answer: C (indicates infection)
ne
la
A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse
tz
that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse
sh
Sp
initiate?
ne
A) Start an IV nitroglycerin infusion.
la
B) Nasogastric lavage with cool saline.
tz
C) Increase the vasopressin infusion.
sh
Sp
D) Prepare for endotracheal intubation. Correct Answer: A
ne
A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep.
la
tz
Which recommendation by the nurse is most effective to assist the client?
sh
A) Losing weight.
Sp
ne
B) Decreasing caffeine intake.
C) Avoiding large meals.
la
sh
Sp
la
Sp
tz
sh
ne
PN Hesi Exit V4 la
tz
An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions.
sh
Sp
When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical
ne
manifestation does the nurse expect to find if nacy's sysmptoms have been caused by a brain attack
la
(stroke)?
tz
A. A carotid bruit
sh
B. A hypotensive blood pressure
Sp
ne
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds Correct Answer: a
la
tz
sh
Which clinical manifestation further supports an assessment of a left-sided brain attack?
Sp
A) Visual field deficit on the left side.
ne
B) Spatial-perceptual deficits.
la
C) Paresthesia of the left side.
tz
sh
D) Global aphasia. Correct Answer: D
Sp
ne
When preparing a patient for a noncontrast computed tomography (CT) scan STAT, what nursing
la
intervention should the nurse implement?
tz
A) Determine if the client has any allergies to iodine
sh
Sp
B) Explain that the client will not be able to move her head throughout the CT scan.
ne
C) Premedicate the client to decrease pain prior to having the procedure.
la
D) Provide an explanation of relaxation exercises prior to the procedure. Correct Answer: B
tz
sh
Sp
A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a patient. Which data
ne
warrants immediate intervention by the nurse concerning this diagnostic test?
A) Elevated blood pressure.
la
tz
B) Allergy to shell fish. sh
C) Right hip replacement.
Sp
ne
D) History of atrial fibrillation. Correct Answer: C
la
A client's daughter is sitting by her mother's bedside who was recently transferred to the Intermediate
tz
sh
Care Unit. She states "I don't understand what a brain attack is. The healthcare provider told me my
Sp
mother is in serious condition and they are going to run several tests. I just don't know what is going on.
ne
What happened to my mother?" What is the best response by the nurse?
la
A) "I am sorry, but according to the Health Insurance Portability and Accounting Act (HIPAA), I cannot
tz
give you any information."
sh
Sp
B) "Your mother has had a stroke, and the blood supply to the brain has been blocked."
ne
C) "How do you feel about what the healthcare provider said?"
la
D) "I will call the healthcare provider so he/she can talk to you about your mother's serious condition."
tz
Correct Answer: B
sh
Sp
ne
What is the normal range for cardiac output? Correct Answer: 4-8L/min
la
tz
A client was admitted with the diagnosis of a brain attack. Their symptoms began 24 hours before being
sh
Sp
admitted. Why would this client not be a candidate for for thrombolytic therapy? Correct Answer:
ne
Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to
admission. This client had symptoms for 24 hours before being brought to the medical center
la
sh
Sp
la
Sp
, ne
tz
sh
ne
la
What are plate guards? Correct Answer: Plate guards prevent food from being pushed off the plate.
tz
Using plate guards and other assistive devices will encourage independence in a client with a self-care
sh
Sp
deficit.
ne
Which condition is considered a non-modifiable risk factor for a brain attack?
la
A) High cholesterol levels.
tz
sh
B) Obesity.
Sp
C) History of atrial fibrillation.
ne
D) Advanced age. Correct Answer: D
la
tz
sh
A client is experiencing homonymous hemianopsia as the result of a brain attack. Which nursing
Sp
intervention would the nurse implement to address this condition?
ne
A) Turn Nancy every two hours and perform active range of motion exercises.
la
B) Place the objects Nancy needs for activities of daily living on the left side of the table.
tz
C) Speak slowly and clearly to assist Nancy in forming sounds to words.
sh
Sp
D) Request that the dietary department thicken all liquids on Nancy's meal and snack trays. Correct
ne
Answer: B
la
tz
A physical therapist (PT) places a gait belt on a client and is assisting them with ambulation from the bed
sh
Sp
to the chair. As they get up out of the bed, they report being dizzy and begin to fall. The PT carefully
ne
allows them to fall back to the bed and notifies the primary nurse. Which written documentation should
la
the nurse put in the client's record?
tz
A) Client experienced orthostatic hypotension when getting out of bed.
sh
B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow
Sp
ne
client to fall back onto the bed.
C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness.
la
D) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance
tz
report completed. Correct Answer: B
sh
Sp
ne
A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs):
la
pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of
tz
sh
these actions by the new graduate is indicated?
Sp
A) Encourage the client to use the incentive spirometer and to cough.
ne
B) Administer oxygen by nasal cannula.
la
C) Request a prescription for sodium bicarbonate from the health care provider.
tz
D) Inform the charge nurse that no changes in therapy are needed. Correct Answer: A
sh
Sp
ne
The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of
la
coronary heart disease (CHD). Which information should the nurse include?
tz
A) Limit dietary selection of cholesterol to 300 mg per day
sh
Sp
B) Increase intake of soluble fiber to 10 to 25 grams per day.
ne
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake. Correct Answer: B
la
tz
sh
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the
Sp
ne
nurse provides the most accurate explanation for use of the splints?
A) Prevention of deformities.
la
sh
Sp
la
Sp
, ne
tz
sh
ne
B) Avoidance of joint trauma.
la
C) Relief of joint inflammation.
tz
D) Improvement in joint strength. Correct Answer: A
sh
Sp
ne
A 32-year-old female client complains of severe abdominal pain each month before her menstrual
period, painful intercourse, and painful defecation. Which additional history should the nurse obtain
la
that is consistent with the client's complaints?
tz
sh
A) Frequent urinary tract infections.
Sp
B) Inability to get pregnant.
ne
C) Premenstrual syndrome.
la
D) Chronic use of laxatives. Correct Answer: B
tz
sh
Sp
A client with a 16-year history of diabetes mellitus is having renal function tests because of recent
ne
fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the
la
nurse conclude as an early symptom of renal insufficiency?
tz
A) Dyspnea.
sh
Sp
B) Nocturia.
ne
C) Confusion.
la
D) Stomatitis. Correct Answer: B
tz
sh
Sp
A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In
ne
determining the possible cause of the bradycardia, the nurse assesses the client's medication record.
la
Which medication is most likely the cause of the bradycardia?
tz
A) Propanolol (Inderal).
sh
B) Captopril (Capoten).
Sp
ne
C) Furosemide (Lasix).
D) Dobutamine (Dobutrex). Correct Answer: A
la
tz
sh
A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which
Sp
assessment finding is of most concern to the nurse?
ne
A) White blood count of 10,000 mm3.
la
B) Serum glucose of 115 mg/dl.
tz
sh
C) Purulent sputum.
Sp
D) Excessive hunger. Correct Answer: C (indicates infection)
ne
la
A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse
tz
that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse
sh
Sp
initiate?
ne
A) Start an IV nitroglycerin infusion.
la
B) Nasogastric lavage with cool saline.
tz
C) Increase the vasopressin infusion.
sh
Sp
D) Prepare for endotracheal intubation. Correct Answer: A
ne
A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep.
la
tz
Which recommendation by the nurse is most effective to assist the client?
sh
A) Losing weight.
Sp
ne
B) Decreasing caffeine intake.
C) Avoiding large meals.
la
sh
Sp
la
Sp
