HESI RN EXIT EXAM COMPREHENSIVE V1-2021 ACTUAL EXAM

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 of 4.5 mEq/L has Kayexalate (sodium polystyrene) prescribed b. 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. …old, has type 1 Diabetes Mellitus, and a recent Hemoglobin A1c of 1… 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 reflex b. 4 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 c. closest living family member d. hospital’s ethics committee 7. The nurse has received report on four clients. The nurse should first assess the client who has: a. Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90% b. Parkinson’s Disease and is demanding to leave the hospital against medical advice (AMA) c. Guillain Barre Syndrome and has begun plasmapheresis therapy d. Heart Failure (CHF) whose pitting edema has increased to 2(+) e. Retinal detachment and is complaining of dark floating spots 8. It would be appropriate to assign which of these tasks to the CNA? a. Feeding a client who is experiencing dysphagia b. One-on-one client observation for safety c. Ambulating a post-op patient for the first-time d. Performing a dressing change 9. The nurse should intervene if a staff member is observed: a. Discussing a client’s diagnosis with visiting family members b. Collaborating with another nurse to review a prescription for blood transfusion c. Interrupting other staff members discussing a client in the cafeteria d. Reviewing a clients lab values with the nutritionist 10. The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse would be correct to include which of the following examples? a. Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is false imprisonment b. Telling a client that you will put in a feeding tube if the client does not eat is an example of battery c. Telling a client with bipolar disorder who is suicidal that they have a right to refuse to take their medications is an example of malpractice d. Placing hands on a client who says “do not touch me” is an example of assault