HESI
.EXIT
.VERSIO
N .3
1. The .nurse .is .reviewing .medical .prescriptions .for .newly
.admitted .clients. .It .would .be .a .priority .for .the .nurse .to .follow
.up .with .the .physician .if .a .client .with
(a) a .potassium .level .of .4.5mEq/L .has .Kayexalate
.(sodium .polystyrene) .prescribed
(b) a .Dilantin .(phenytoin) .level .of .8 .mcg/ml .is .placed .on
.seizure .precautions(c) .sensitivity .to .Aspirin
.(acetylsalicylic .acid) .is .prescribed .Tylenol
.(acetaminophen)
(d) . sensitivity . to . Penicillin . is . prescribed . Zithromax . (azithromycin)
2. The . nurse . should . intervene . if . the . nurse . notes . a . staff . member
(a) obtaining .a .clients .consent .prior .to .their .operative
.procedure .after .receiving .Ativan .(lorazepam)
(b) placing .a .client .on .the .affected .side .following .surgical
.repair .of .a .retinal .detachment
(c) handling . a . wet .cast .with .the . palms . of .the . hands
(d) using . a . broad .base . of .support . while . transferring . a .client
3. The .community .health .nurse .is .caring .for .the .following .clients. .It
.would .be .a .priority .for .the .nurse .to .initiate .a .multidisciplinary
.conference .for .the .client .who .is
,(a) 12 . years . old . with . Autism . who . is . starting . a . new . school . and
,recently .had .a .URI .(upper .respiratory . tract .infection)
, (b) 16 .years .old, .has .type .1 .Diabetes .Mellitus, .is .unemployed
.and .had .a .recent .Hemoglobin .A1c .of .13%
(c) 52 .years .old, .with .Myasthenia .Gravis, .recently
.prescribed .Mestinon .(pyridostigmine) .and .employed .as
.a .mail .carrier
(d) 70 .years .old, .has .schizophrenia, .lives .alone .and
.reports .hearing .non .threatening .voices.
4. The .nurse .from .the .postpartum .unit .has .been .temporarily
.assigned .to .the .medical .surgical .unit. . It .would .be .most
.appropriate . to .assign .this .nurse .to .the .client .who*
(a) has .returned .from .right .total .hip .replacement .surgery .four .hours .ago
(b) is . being . observed . for . increased .intracranial . pressure
(c) had . surgery . two . hours . ago . to .remove . the . appendix
(d) is .two .weeks .post .partum .being .maintained .on .a
.mechanical .ventilator .for .respiratory .failure
5. The .nurse .in .a .well .baby .clinic .has .assessed .several .children
.today. .It .would .be .a .priority . for .the .nurse .to .suggest .follow .up
.for .the . child .who .is .(a) .2 .months .old .with .a .positive .babinski
.refl .ex
(b) 5 .months .old .and .does .not .hold .their .own .bottle
(c) 10 .months .old .who .cries .around .strangers
(d) 18 .months .old .who .needs .support .while .ambulating
6. The .nurse .is .caring .for .a .mechanically .ventilated .client .who .was
.declared .brain .dead. .An .Advance .Directive .is .not .documented .on
. the . medical . record. . It . would . be . most . appropriate . to . obtain
.consent .for .organ .donation .from .the
(a) client‘s . primary . care . provider
(b) client‘s . nurse . manager
.EXIT
.VERSIO
N .3
1. The .nurse .is .reviewing .medical .prescriptions .for .newly
.admitted .clients. .It .would .be .a .priority .for .the .nurse .to .follow
.up .with .the .physician .if .a .client .with
(a) a .potassium .level .of .4.5mEq/L .has .Kayexalate
.(sodium .polystyrene) .prescribed
(b) a .Dilantin .(phenytoin) .level .of .8 .mcg/ml .is .placed .on
.seizure .precautions(c) .sensitivity .to .Aspirin
.(acetylsalicylic .acid) .is .prescribed .Tylenol
.(acetaminophen)
(d) . sensitivity . to . Penicillin . is . prescribed . Zithromax . (azithromycin)
2. The . nurse . should . intervene . if . the . nurse . notes . a . staff . member
(a) obtaining .a .clients .consent .prior .to .their .operative
.procedure .after .receiving .Ativan .(lorazepam)
(b) placing .a .client .on .the .affected .side .following .surgical
.repair .of .a .retinal .detachment
(c) handling . a . wet .cast .with .the . palms . of .the . hands
(d) using . a . broad .base . of .support . while . transferring . a .client
3. The .community .health .nurse .is .caring .for .the .following .clients. .It
.would .be .a .priority .for .the .nurse .to .initiate .a .multidisciplinary
.conference .for .the .client .who .is
,(a) 12 . years . old . with . Autism . who . is . starting . a . new . school . and
,recently .had .a .URI .(upper .respiratory . tract .infection)
, (b) 16 .years .old, .has .type .1 .Diabetes .Mellitus, .is .unemployed
.and .had .a .recent .Hemoglobin .A1c .of .13%
(c) 52 .years .old, .with .Myasthenia .Gravis, .recently
.prescribed .Mestinon .(pyridostigmine) .and .employed .as
.a .mail .carrier
(d) 70 .years .old, .has .schizophrenia, .lives .alone .and
.reports .hearing .non .threatening .voices.
4. The .nurse .from .the .postpartum .unit .has .been .temporarily
.assigned .to .the .medical .surgical .unit. . It .would .be .most
.appropriate . to .assign .this .nurse .to .the .client .who*
(a) has .returned .from .right .total .hip .replacement .surgery .four .hours .ago
(b) is . being . observed . for . increased .intracranial . pressure
(c) had . surgery . two . hours . ago . to .remove . the . appendix
(d) is .two .weeks .post .partum .being .maintained .on .a
.mechanical .ventilator .for .respiratory .failure
5. The .nurse .in .a .well .baby .clinic .has .assessed .several .children
.today. .It .would .be .a .priority . for .the .nurse .to .suggest .follow .up
.for .the . child .who .is .(a) .2 .months .old .with .a .positive .babinski
.refl .ex
(b) 5 .months .old .and .does .not .hold .their .own .bottle
(c) 10 .months .old .who .cries .around .strangers
(d) 18 .months .old .who .needs .support .while .ambulating
6. The .nurse .is .caring .for .a .mechanically .ventilated .client .who .was
.declared .brain .dead. .An .Advance .Directive .is .not .documented .on
. the . medical . record. . It . would . be . most . appropriate . to . obtain
.consent .for .organ .donation .from .the
(a) client‘s . primary . care . provider
(b) client‘s . nurse . manager
