HESI "400" RN Exit Exam
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1. The healthcare provider prescribes potassium chlo- 12.5
ride 25 mEq in 500 ml D_5W to infuse over 6 hours. The Rationale: Using the for-
available 20 ml vial of potassium chloride is labeled, mula D / H X Q: 25 mEq /
"10 mEq/5ml." how many ml of potassium chloride 10 mEq x 5ml ꞊12.5ml
should the nurse add the IV fluid? (Enter numeric val-
ue only. If is rounding is required, round to the nearest
tenth.)
2. Assessment by the home health nurse of an older b. Include oatmeal with
client who lives alone indicates that client has chron- stewed pruned for break-
ic constipation. Daily medications include furosemide fast as often as possible.
for hypertension and heart failure, and laxatives. To c. Increase fluid intake by
manage the client's constipation, which suggestions keeping water glass next
should the nurse provide? (Select all that apply) to recliner.
d. Recommend seeking
a. Decrease laxative use to every other day and use oil help with regular shop-
retention enemas as needed. ping and meal prepara-
b. Include oatmeal with stewed pruned for breakfast tion.
as often as possible.
c. Increase fluid intake by keeping water glass next to Rational: older adult are
recliner. at higher risk for chron-
d. Recommend seeking help with regular shopping ic constipation due to
and meal preparation. decreased gastrointesti-
e. Report constipation to healthcare provider related nal muscle tone leading
to cardiac medication side effects. to reduce motility. Oat-
meal with prunes increas-
es dietary fiber and bow-
el stimulation, thereby de-
creasing need for laxa-
tives. Increased fluid in-
take also decreases con-
stipations. Assistance with
, HESI "400" RN Exit Exam
Study online at https://quizlet.com/_dge5tu
food preparation might
help the client eat more
fresh fruits and vegeta-
bles and result on less re-
liance on microwaved and
fast foods, which are usu-
ally high in sodium and fat
with little fiber. Laxatives
can be reduced gradual-
ly by improving the diet,
without resorting to using
enemas.
3. An older adult male who had an abdominal cholecys- b. Report mental status
tectomy has become increasingly confused and dis- change to the healthcare
oriented over the past 24 hours. He is found wander- provider
ing into another client's room and is return to his room c. Assess the client's
by the unlicensed assistive personnel (UAP). What ac- breath sounds and oxy-
tions should the nurse take? (Select all that apply). gen saturation
e. Review the client's most
a. Apply soft upper limb restrains and raise all four bed recent serum electrolyte
rails values
b. Report mental status change to the healthcare
provider Rationale: The healthcare
c. Assess the client's breath sounds and oxygen satu- provider should be in-
ration formed of changes in the
d. Assign the UAP to re-assess the client's risk for falls client's condition (B) be-
e. Review the client's most recent serum electrolyte cause this behavior may
values indicate a postoperative
complication. Diminished
oxygenation (C) and elec-
trolyte imbalance (E) may
, HESI "400" RN Exit Exam
Study online at https://quizlet.com/_dge5tu
cause increased confusion
in the older adult. Rais-
ing all four bed rails (A)
may lead to further in-
jury if the client climbs
over the rails and falls and
restrains should not be
applied until other mea-
sures such as re-orienta-
tion are implemented. The
nurse should assess the
client's increased risk for
falls, rather than assigning
this to the UAP (D).
4. An adult client with schizophrenia begin treatment Obtain a prescription for
three days ago with the Antipsychotic risperidone. an anticholinergic med-
The client also received prescription for trazodone as ication
needed for sleep and clonazepam as needed for se-
vere anxiety. When the client reports difficulty with Rationale: Antipsychotic
swallowing, what action should the nurse take? medications have an ex-
trapyramidal side effects
a. Obtain a prescription for an anticholinergic medica- one of which is difficult
tion to swallowing the nurse
b. Determine how many hours declined slept last should obtain a prescrip-
night tion for an anticholiner-
c. Administer the PRN prescription for severe anxiety gic medication which is
d. Watch the thyroid cartilage move while the client used for the treatment of
swallows extrapyramidal symptoms.
Other options are not war-
ranted actions based on
the symptoms presented.
, HESI "400" RN Exit Exam
Study online at https://quizlet.com/_dge5tu
5. A client in the intensive care unit is being mechanically c. Auscultated bilateral
ventilated, has an indwelling urinary catheter in place, breath sounds
and is exhibiting signs of restlessness. Which action
should the nurse take first? Rationale: Restlessness
often results from de-
a. Review the heart rhythm on cardiac monitors creased oxygenation, so
b. Check urinary catheter for obstruction breath sounds should be
c. Auscultated bilateral breath sounds assessed first. Giving an
d. Give PRN dose of lorazepam (Ativan) anxiolytic such as lo-
razepam, might be indi-
cated but first the client
should be assessed for the
cause of the restlessness.
An obstruction in the uri-
nary drainage system can
cause a distended blad-
der that may result in rest-
lessness, but patent air-
way is the priority inter-
vention. The client should
be assessed before eval-
uating the cardiac rhythm
on the monitor.
6. The nurse observes that a postoperative client with a B. observe the amount of
continuous bladder irrigation has a large blood clot in urine in the clients urinary
the urinary drainage tubing. What action should the drainage bag.
nurse perform first?
Rationale: If blood clots
A. determine the client's blood pressure and apical are present, the nurse
pulse should first determine if
B. observe the amount of urine in the clients urinary urinary output has be-
Study online at https://quizlet.com/_dge5tu
1. The healthcare provider prescribes potassium chlo- 12.5
ride 25 mEq in 500 ml D_5W to infuse over 6 hours. The Rationale: Using the for-
available 20 ml vial of potassium chloride is labeled, mula D / H X Q: 25 mEq /
"10 mEq/5ml." how many ml of potassium chloride 10 mEq x 5ml ꞊12.5ml
should the nurse add the IV fluid? (Enter numeric val-
ue only. If is rounding is required, round to the nearest
tenth.)
2. Assessment by the home health nurse of an older b. Include oatmeal with
client who lives alone indicates that client has chron- stewed pruned for break-
ic constipation. Daily medications include furosemide fast as often as possible.
for hypertension and heart failure, and laxatives. To c. Increase fluid intake by
manage the client's constipation, which suggestions keeping water glass next
should the nurse provide? (Select all that apply) to recliner.
d. Recommend seeking
a. Decrease laxative use to every other day and use oil help with regular shop-
retention enemas as needed. ping and meal prepara-
b. Include oatmeal with stewed pruned for breakfast tion.
as often as possible.
c. Increase fluid intake by keeping water glass next to Rational: older adult are
recliner. at higher risk for chron-
d. Recommend seeking help with regular shopping ic constipation due to
and meal preparation. decreased gastrointesti-
e. Report constipation to healthcare provider related nal muscle tone leading
to cardiac medication side effects. to reduce motility. Oat-
meal with prunes increas-
es dietary fiber and bow-
el stimulation, thereby de-
creasing need for laxa-
tives. Increased fluid in-
take also decreases con-
stipations. Assistance with
, HESI "400" RN Exit Exam
Study online at https://quizlet.com/_dge5tu
food preparation might
help the client eat more
fresh fruits and vegeta-
bles and result on less re-
liance on microwaved and
fast foods, which are usu-
ally high in sodium and fat
with little fiber. Laxatives
can be reduced gradual-
ly by improving the diet,
without resorting to using
enemas.
3. An older adult male who had an abdominal cholecys- b. Report mental status
tectomy has become increasingly confused and dis- change to the healthcare
oriented over the past 24 hours. He is found wander- provider
ing into another client's room and is return to his room c. Assess the client's
by the unlicensed assistive personnel (UAP). What ac- breath sounds and oxy-
tions should the nurse take? (Select all that apply). gen saturation
e. Review the client's most
a. Apply soft upper limb restrains and raise all four bed recent serum electrolyte
rails values
b. Report mental status change to the healthcare
provider Rationale: The healthcare
c. Assess the client's breath sounds and oxygen satu- provider should be in-
ration formed of changes in the
d. Assign the UAP to re-assess the client's risk for falls client's condition (B) be-
e. Review the client's most recent serum electrolyte cause this behavior may
values indicate a postoperative
complication. Diminished
oxygenation (C) and elec-
trolyte imbalance (E) may
, HESI "400" RN Exit Exam
Study online at https://quizlet.com/_dge5tu
cause increased confusion
in the older adult. Rais-
ing all four bed rails (A)
may lead to further in-
jury if the client climbs
over the rails and falls and
restrains should not be
applied until other mea-
sures such as re-orienta-
tion are implemented. The
nurse should assess the
client's increased risk for
falls, rather than assigning
this to the UAP (D).
4. An adult client with schizophrenia begin treatment Obtain a prescription for
three days ago with the Antipsychotic risperidone. an anticholinergic med-
The client also received prescription for trazodone as ication
needed for sleep and clonazepam as needed for se-
vere anxiety. When the client reports difficulty with Rationale: Antipsychotic
swallowing, what action should the nurse take? medications have an ex-
trapyramidal side effects
a. Obtain a prescription for an anticholinergic medica- one of which is difficult
tion to swallowing the nurse
b. Determine how many hours declined slept last should obtain a prescrip-
night tion for an anticholiner-
c. Administer the PRN prescription for severe anxiety gic medication which is
d. Watch the thyroid cartilage move while the client used for the treatment of
swallows extrapyramidal symptoms.
Other options are not war-
ranted actions based on
the symptoms presented.
, HESI "400" RN Exit Exam
Study online at https://quizlet.com/_dge5tu
5. A client in the intensive care unit is being mechanically c. Auscultated bilateral
ventilated, has an indwelling urinary catheter in place, breath sounds
and is exhibiting signs of restlessness. Which action
should the nurse take first? Rationale: Restlessness
often results from de-
a. Review the heart rhythm on cardiac monitors creased oxygenation, so
b. Check urinary catheter for obstruction breath sounds should be
c. Auscultated bilateral breath sounds assessed first. Giving an
d. Give PRN dose of lorazepam (Ativan) anxiolytic such as lo-
razepam, might be indi-
cated but first the client
should be assessed for the
cause of the restlessness.
An obstruction in the uri-
nary drainage system can
cause a distended blad-
der that may result in rest-
lessness, but patent air-
way is the priority inter-
vention. The client should
be assessed before eval-
uating the cardiac rhythm
on the monitor.
6. The nurse observes that a postoperative client with a B. observe the amount of
continuous bladder irrigation has a large blood clot in urine in the clients urinary
the urinary drainage tubing. What action should the drainage bag.
nurse perform first?
Rationale: If blood clots
A. determine the client's blood pressure and apical are present, the nurse
pulse should first determine if
B. observe the amount of urine in the clients urinary urinary output has be-
