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HESI RN Exit Exam Prep Guide: High-Performance
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A 35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery? a- Supplemental hormonal therapy will probably be unnecessary b- The thyroid will regenerate to a normal size within a few years. c- The client will be restricted from eating seafood d- The remainder of the thyroid will be removed at a later date. - CORRECT ANS- - c. The client will be restricted from eating seafood A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? a- Prepare the client for an emergency cesarean birth b- Encourage the client to move to a hands-and-knees position. c- Assist the client to sharply flex her thighs up again the abdomen. d- Lower the head of the bed an apply suprapubic pressure. - CORRECT ANS- - c. Assist the client to sharply flex her thighs up again the abdomen. The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic? a- Low bioavailability
b- Rapid onset of action c- Short half life d- Narrow therapeutic index. - CORRECT ANS- - d. Narrow therapeutic index. Rationale: Narrow therapeutic index (NTI) drugs are defined as those drugs where small differences in dose or blood concentration may lead to dose and blood concentration dependent, serious therapeutic failures or adverse drug reactions. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? a- Decreased abdominal girth b- Increased blood pressure c- Clear breath sounds d- Decrease serum albumin. - CORRECT ANS- - a. Decreased abdominal girth When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do? a- Check for any abrasions or bruises. b- Help the client to stand. c- Get a blood pressure cuff. d- Report the fall to the nurse-manager. - CORRECT ANS- - c. Get a blood pressure cuff. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?
The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress? a- Contractions of the sternocleidomastoid muscle. b- Respiratory rate of 20 breath/mints c- Downward movement of diaphragm with inspiration d- A pulse oximetry reading of SpO2 95% - CORRECT ANS- - a. Contractions of the sternocleidomastoid muscle Rationale: Force inspiration needs to use accessories muscle and rib cage. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement? a- Send stool specimen to the lab b- Measure abdominal girth c- Encourage increased fiber in diet. d- Monitor mental status. - CORRECT ANS- - d. Monitor mental status. Rationale: Administer lactulose to a patient with hepatic encephalopathy to lower serum ammonia level, so mental status should be improving. A client present at the clinic with blepharitis. What instructions should the nurse provide for home care? a- Use bilateral eyes patches while sleeping to prevent injury to eyes. b- Wear sunglasses when out of doors to prevent photophobia
c- Apply warm moist compresses then gently scrub eyelids with diluted baby shampoo - CORRECT ANS- - d. Apply warm moist compresses then gently scrub eyelids with diluted baby shampoo Rationale: This condition is an inflammation of the eyelids edges that occurs in older adults. Is controlled with eyelid care using warm moist compresses followed by gently scrub eyelids. Dopamine protocol is prescribed for a male client who weigh 198 pounds to maintain the mean arterial pressure (MAP) greater than 65 mmHg. His current MAP is 50 mmHg, so the nurse increases the infusion to 7 mcg/kg/minute. The infusion is labeled dextrose 5% in water (D5W) 500 ml with dopamine 400 mg. The nurse should program the infusion pump to deliver how many ml/hour? 47 - CORRECT ANS- - 47 The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? (Select all that apply) a- Discontinue medication when palpitation subside. b- Avoid eating grapefruit or drinking grapefruit juice. c- Report changes in the use of daily supplements d- Notify your health care provider if your skin looks yellow e- If a dose is missed, the next dose should be double. - CORRECT ANS- - b- Avoid eating grapefruit or drinking grapefruit juice. c- Report changes in the use of daily supplements d- Notify your health care provider if your skin looks yellow
While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition? a- Tinea corporis b- Herpes zoster c- Psoriasis d- Drug reaction - CORRECT ANS- - c. Psoriasis Rationale: Psoriasis is typically located on the elbow and knees A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply) a- Monitor heart, lung, and kidney function. b- Notify healthcare provider of serum amylase and lipase levels. c- Position client on abdomen to provide organ stability d- Encourage an increased intake of clear oral fluids e- Review client's abdominal ultrasound findings. - CORRECT ANS- - a- Monitor heart, lung, and kidney function. b- Notify healthcare provider of serum amylase and lipase levels. e- Review client's abdominal ultrasound findings. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?
a- Hypernatremia b- Excessive thirst c- Elevated heart rate d- Poor skin turgor - CORRECT ANS- - a. Hypernatremia Rationale: Hypernatremia can lead to neurological symptoms, such as overactivity in the brain and nerve muscles, confusion, seizures, or even coma. Without treatment, central diabetes inspidus can lead to permanent kidney damage. In caring for a client receiving the aminoglycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test? a- Urinalysis b- Serum creatinine c- Serum osmolarity d- Liver enzymes. - CORRECT ANS- - b- Serum creatinine Rationale: Aminoglycosides can cause nephrotoxicity, so it is important for the nurse to monitor the serum creatinine level which can monitor the renal function. A client who is at 36 weeks gestation is admitted with severe preeclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse? A. Urine output 20 ml/hour B. Blood pressure 138/ C. Respiratory rate 18 breaths/min
e- Keep a diet record to monitor calcium intake Rationale: Twitching and seizure are signs of low calcium. (A) Vit D supplement with calcium to enhance calcium absorption, especially in older adults. Dairy product should be included in the diet. Keeping a food record is a good healthcare practice. Foods high in calcium are recommended to maintain normal calcium level and it is important to verify if the client has allergy to shellfish. The husband of a client with advanced ovarian cancer wants his wife to have every treatment available. When the husband leaves, the client tells the nurse that she has had enough chemotherapy and wants to stop all treatments but knows her husband will sign the consent form for more treatment. The nurse's response should include which information? a- The husband cannot sign the consent for the client, her signature is required b- The client's specific wishes should be discussed with her healthca - CORRECT ANS- - a- The husband cannot sign the consent for the client, her signature is required b- The client's specific wishes should be discussed with her healthcare provider d- The healthcare team will formulate a plan of care to keep the client comfortable Rationale: An adult client who is mentally competent has the autonomy and the client's right to make her own decision regarding her treatment. The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin SHOCK... medication? a- Dilute the Dextrose in one liter of 0.9% Normal Saline solution. b- Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml. c- Push the undiluted Dextrose slowly through the currently infusion IV.
d- Ask the pharmacist to add the Dextrose to a TPN solution. - CORRECT ANS- - c. Push the undiluted Dextrose slowly through the currently infusion IV Rationale: To reverse life-threatening insulin shock, the nurse should administer the 50% Dextrose infusing IV. The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living (ADLs) due to aging. Which options should the nurse discuss with the daughter? a. Home hospice agency b. Long-term care facility c. Rehabilitation facility d. Independent senior apartment e. Home health agency - CORRECT ANS- - b. Long-term care facility e. Home health agency Long term care facilities and home health agencies performs ADLs. Hospice provides empathetic, attentive care for dying. C provide physical therapy to strengthen a part of the body. A male client with cancer, who is receiving antineoplastic drugs, is admitted to the... what findings is most often manifest this condition? a. Ecchymosis and hematemesis b. Weight loss and alopecia c. Weakness and activity intolerance d. Sore throat and fever - CORRECT ANS- - a. Ecchymosis and hematemesis
b. Press down on the device after breathing in fully c. Move the device one to two inches away from the mouth d. Breathe out slowly and deeply while compressing the device - CORRECT ANS- - c. Move the device one to two inches away from the mouth Rationale: Optimal position of a metered dose inhaler includes placing the inhaler one two inches away from the mouth. A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother... During the assessment, the mother asks the nurse why her child is at the 5th percent...response is best for the nurse to provide? a. Does your child seem mentally slower than his peers also? b. "His smaller size is probably due to the heart disease" c. Haven't you been feeding him according to recommended daily allowances for children? d. You should not worry about the growth tables. They are only averages - CORRECT ANS- - b. "His smaller size is probably due to the heart disease" Rationale: Poor growth patterns are associated with heart disease. A client with hypertension receives a prescription for enalapril, an angiotensin... instruction should the nurse include in the medication teaching plan? a. Increase intake of potassium-rich foods b. Report increased bruising of bleeding c. Stop medication if a cough develops d. Limit intake of leafy green vegetables - CORRECT ANS- - b. Report increased bruising of bleeding
Rationale: ACEIs can cause thrombocytopenia and increased risk for bruising and bleeding. A is not necessary because is a potassium-sparing When administering ceftriaxone sodium (Rocephin) intravenously to a client before... most immediate intervention by the nurse? a. Stridor b. Nausea c. Headache d. Pruritus - CORRECT ANS- - a. Stridor Rationale: Stridor, a crowing respiration, indicates the client is experiencing bronchospasm, as a reaction to Rocephin, and antibiotic. The finding requires immediate action by the nurse. B and C are side effects that are not life-threatening. Pruritus may be the result as... and need nursing intervention but is of less immediacy than stridor. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? a. Hypoactive bowel sounds in the lower quadrant. b. Rebound tenderness in the upper quadrants. c. Tympani with percussion of the abdomen. d. Light colors gastric aspirate via the nasogastric tube. - CORRECT ANS- - b. Rebound tenderness in the upper quadrants
d- Reduce the risk for injury - CORRECT ANS- - d. Reduce the risk for injury Rationale: Paget's is a metabolic bone disorder which place the client at high risk for injury. Once the client is symptom free the next goal is reducing risk for injury The mother of a one-month-old boy born at home brings the infant to his first well...was born two weeks after his due date, and that he is a "good, quiet baby" who almost... hypothyroidism, what question is most important for the nurse to ask the mother? a. Has your son had any immunizations yet? b. Is your son sleepy and difficult to feed? c. Are you breastfeeding or bottle feeding your son? d. Were any relatives born with birth defects? - CORRECT ANS- - b. Is your son sleepy and difficult to feed? Rationale: Like adults with hypothyroidism, excess fatigue is common and a "good" baby is of.... occurs with hypothyroidism and can result in poor sucking. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)? a- An older client who fell yesterday and is now complaining of diplopia b- An adult newly diagnosed with type 1 diabetes and high cholesterol c- A client with pancreatic cancer who is experience intractable pain. d- An older client post-stroke who is aphasic with right-sided hemiplegia - CORRECT ANS- - a. An older client post-stroke who is aphasic with right-sided hemiplegia
Following a gun shot wound to the abdomen, a young adult male had an emergency bowel...Multiple blood products while in the operating room. His current blood pressure is 78/52...He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values...Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first? a. Transfuse packed red blood c - CORRECT ANS- - a. Transfuse packed red blood cells Rational: The client is exhibiting signs of multiple organ dysfunction syndrome. Transfusion is the first intervention which provide hemoglobin to carry the oxygen to the tissues, is critical. After checking the fingerstick glucose at 1630, what action should the nurse implement? a. Notify the healthcare provider b. Administer 8 units of insulin aspart SubQ c. Gives an IV bolus of Dextrose 50% 50 ml d. Perform quality control on the glucometer. - CORRECT ANS- - b. Administer 8 units of insulin aspart SubQ Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscul...Which finding warrants immediate intervention by the nurse? a. Extremity muscle weakness b. Bilateral eyelid drooping c. Inability to swallow pills d. Evidence of hypoventilation - CORRECT ANS- - d. Evidence of hypoventilation
b. Assess the client pain level frequently c. Observe for appropriate interaction with the infants. d. Assess fundal tone and lochia flow - CORRECT ANS- - b. Assess fundal tone and lochia flow Rationale D is the priority intervention because is a multigravida and this pregnancy predisposes the client to uterine atony which could result in hemorrhage. A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being...18 months-old child and lives in a rural area. Her husband takes the family car to work daily...transportation during the day. What intervention is most important for the nurse to implement? a. Teach a client amount the use of a home pregnancy test. b. Schedule a weekly home visit to draw hCG values. c. Make a 5 week follow- up with healthcare provider d. Begin chemotherapy administration during the first - CORRECT ANS- - b. Schedule a weekly home visit to draw hCG values Rationale: To monitor for development of choriocarcinoma, a complication TD, level of hCG should be monitor for negative results. A newly graduated female staff nurse approaches the nurse manager and request reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide? a. I have to call the supervisor to get someone else to transfer to this unit to care for him. b. I know you are good nurse and can handle this client in a professional manner.
c. I'll talked to the client about his sexual harassment and I'll insist that - CORRECT ANS- - d. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client. After removing a left femoral arterial sheath, which assessment findings warrant immediate interventions by the nurse? (Select all that applied.) a- Tenderness over insertion b- Unrelieved back and flank pain. c- Cool and pale left leg and foot. d- Left groin egg-size hematoma. e- Quarter size red drainage at site. - CORRECT ANS- - b- Unrelieved back and flank pain. c- Cool and pale left leg and foot. d- Left groin egg-size hematoma. Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis? a. Begin a weight-bearing exercise plan b. Increase intake of foods rich in calcium c. Schedule a bone density tests every year. d. Remain upright after taking the medication. - CORRECT ANS- - d. Remain upright after taking the medication Rationale: Risendronate, causes reflux and esophageal erosion.
