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HESI PN ACTUAL EXIT EXAM 202 4 QUESTIONS
AND VERIFIED ANSWERS GRADED A+
LATEST
The nurse is planning care for the a client who has fourth degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priority?
A. Administer Prescribed stool softner
B. Administer prescribed PRN sleep medications.
C. Encourage breastfeeding to promote uterine involution
D. Encourage use of prescribed analgesic perineal sprays.
A. Administer Prescribed stool softner
The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area.
A. Duodenum
B. Gastric Pylorus
C. Liver
D. Spleen
C. Liver
A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report?
A. Decreased sexual libido
B. Amenorrhea
C. Quickening
D. Nocturia
B Amenorrhea
A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make?
A. Ask for a description of what happened during the night
B. Tell the daughter to talk to the unit's nurse manager
C. Reassure the daughter that the mother will get better care.
D. Explain that all the staff are doing the best they can.
A. Ask for a description of what happened during the night
A hosptitalized toddler who is recovering from a sickle cell crisis holds a toy and say's "mine". According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage?
A. Autonomy vs. Shame and doubt.
B. Industry vs. Inferiority
What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space?
A. Filtration
B. Diffusion
C. Osmosis
D. Active transport
C. Osmosis
The nurse is taking blood presure of a client admitted with a possible myocardial infarction. When taking the client's BP at the brachial artery, the nurse should place the client's arm in which position?
A. Slightly above the level of the heart
B. At the level of the heart
C. At the level of comfort for the client
D. Below the level of the heart
B. At the level of the heart
What are the final parameters that produce blood pressure? (select all that apply)
A. Heart rate
B. Stroke volume
C. Peripheral resistance
D. Neuroendocring hormones
E. Muscle tone
A. Heart rate
B. Stroke volume
C. Peripheral resistance
A client begins an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant?
A. Appetite
B. Mood
C. Withdrawl
D. Energy level
B. Mood
Based on the documentation in the medical record, which action should the nurse implement next?
A. Give the rubella vaccine subcutaneously
B. Observe the mother breastfeeding her infant
C. Call the nursery for the infant's blodd type result
D. Monitor a continous narcotic epidural for a postoperative client
C. Observe a client rotate the subcutaneous site for an insulin pump
After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the unlicensed assistive personnel?
A. Identify the need for additional supplies to provide an extra dressing change
B. Provide perianal care and collect clean linens for the dressing change
C. Document the diarrhea that necessitates an additional dressing change
D. Position the client for access to the decubiti sties and remove dressings
B. Provide perianal care and collect clean linens for the dressing change
The nurse is planning to evaluate the effectiveness of several drugs administered by different routes. Arrage the routes of administration in the order from fastest to slowest rate of absorption.
Subcutaenous
Intravenous
Intramuscular
Sublingual
Oral
Intravenous, sublingual, intramuscular, subcutaneous, oral.
A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-house post dilation and curettage (D&C) the nurse assess the vital signs and vaginal bleeding. The client begins to cry softly. How should the nurse intervene?
A. Offer to call the social worker to discuss the possiblity of abortion
B. Reassure the client that the infertility specialist can help
C. Express sorrow for the client's grief and offer to sit with her
D. Chart the vital signs and amount of vaginal bleeding
C. Express sorrow for the client's grief and offer to sit with her
A terminally ill male client and his family are requesting hospice care after discharge from the hosptial and ask the nurse to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care?
A. Enhance symptom management to improve end of life quality
B. facilitates assisted suicide with the client's consent
C. Offers ways to postpone the death experience at home
D. Provide training for family members to care for the client.
A. Enhance symptom management to improve end of life quality
The nurse observes a wife shaving her husband's beard with a safety razor by holding the skin taut and shaving in the direction of the hair growth. What action should the nurse take?
A. Advsie the wife to shave against the hair growth
B. Teach the wife to keep the skin loose to avoid cuts
The nurse is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catherterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's PO intake is 600 mL, and fifteen minutes ago, the client voided 90 mL. What action should the nurse take?
A. Stand the client to void and run tap water within hearing distance before catheterizing the client.
B. Straight catheterize and if the residual uring volume is greater than 100 mL, clamp catheter
C. Catheterize q2H and place in an indwelling catheter at the end of the prescribed 24hr period.
D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon.
D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon.
A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the nurse recognize as Cushionoid side effects?
A. Moon face, Slow wound healing, muscle wasting sodium and water retention
B. Tachycardia hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor
C. Bradycardia, weight gain, cold intolerance, myxedema facies and periobarbital edema
D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension
A. Moon face, Slow wound healing, muscle wasting sodium and water retention
The cervix is the opening into the uterine cavity. What is its function in reproduction?
A. Accepts and interprets signals of sexual stimuli
B. Secretes mucus to facilitate sperm transport
C. Serves as the site for union of ovum ans sperm
D. Receives the penis during intercourse
B. Secretes mucus to facilitate sperm transport
The nurse is working in a community health setting and assisting the charge nurse in performing health screenings. Which individual is at highest risk for contracting an HIV infection?
A. 17-year-old who is sexually active simultaneously with numerous partners
B. 34-year old homosexual who is in a monogamous relationship
C. 30-year-old cocaine user who inhales and smokes drugs
D. 45-year-old who has received two blood transfusions in the past 6 months
A. 17 - year-old who is sexually active simultaneously with numerous partners
The nurse is administering amiodarone (Cordarone) to a client who has been admitted with Atrial Fibrillation (AFIB). What therapeutic response should the nurse anticipate?
A. Conversion of irregular heart rate to regular heart rhythm
B. Pulse oximetry readings within normal range during activity
C. Peripheral pulse points with adequate capillary refill
D. Increase excercise tolerance without shortness of breath
A. Conversion of irregular heart rate to regular heart rhythm
C. Ask the client to breathe deeply and slowly exhale
D. Inflate the balloon with 5mL of sterile water
B. Insert the catheter an additional inch
A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a lumber Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality?
A. Mild electrical stimulus on the skin surface closes the gates of nerve conduction for sever pain
B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
C. An infusion of medication in the spinal canal will block pain perception
D. The discharge of electricity will distract the client's focus on the pain
B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
Based on the Nursing diagnosis of "Potential for infection related to second and third degree burns," which intervention has the highest priority?
A. Application of topical antibacterial cream
B. Use of careful hand washing technique
C. Administration of plasma expanders
D. Limiting visitors to the burned client.
B. Use of careful hand washing technique
The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder, which assessment finding is the most significant indicator of possible child abuse?
A. The child looks at the floore when answering the nurse's questions
B. The mother's version of the injury is different from the child's version
C. The child has several abrasions on the chest and legs
D. The mother refuses to answer questions about family history
D. The mother refuses to answer questions about family history
A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take?
A. Contact the pharmacy and request the prescribed form of aspirin
B. Instruct the client about the effects when given the medication
C. Administer the aspirin with a full glass of water or a small snack
D. Withhold the aspirin until consulting with the healthcare provider
C. Administer the aspirin with a full glass of water or a small snack
The nurse explains the 2-week dosage prescription of prednison (Deltasone) to a client who has poison ivy over multiple skin surfaces. What should the nurse emphasize about the dosing schedule?
A. Decrease dosage daily as prescribed
B. Monitor oral temperature daily
A new mother is at the clinic with her 4-week old for a well baby check up. The nurse should tell the mother to anticipate that the infant will demonstrate which millstone by 2-months of age.
A. Turns from side to back and returns
B. Consistently returns smiles to mother
C. Finds hands and plays with fingers
D. Holds head up and supports weight with arms
B. Consistently returns smiles to mother
The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen and teh infusion rate is slower than the prescribed rate. What is the most likely cause of this finding?
A. The solution's rate is too rapid
B. The client has phlebitis
C. The infusion site is infected
D. The infusion site is infiltrated
D. The infusion site is infiltrated
The nurse observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement?
A. Raise the bed to ensure the drainage bag remains off the floor
B. Attach the drainage bag to the side rail instead of the bed frame
C. Observe the appearance of the urine in the drainage tubing
D. Secure the tubing to the client's gown instead of his abdomen
C. Observe the appearance of the urine in the drainage tubing
In assisting a client to obtain a putum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?
A. Advise the client that suctionin will be used to obtain another specimen
B. Re-instruct the client in coughing techniques to obtain another specimen
C. Provide the client a glass of water and mouthwash to rinse the mouth
D. Label the container and place the container in a biohazard transport bag
B. Re-instruct the client in coughing techniques to obtain another specimen
After report, the nurse receives the laboratory values for 4 clients. Which client requires the nurse's immediate intervention? The client who is.....
A. short of breath after a shower and has a hemoglobin of 8 grams
B. Beleeding from a finger stick and has a prothrombin time of 30 seconds
C. Febrile and has a WBC count of 14,000/mm
D. Trembling and has a glucose level of 50 mg/dL
Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?
A. Temperature of 100.8F
B. A pulse rate of 150 beats per minute
C. A respiratory rate of 10 breaths per minute
D. A blood pressure of 180/
C. A respiratory rate of 10 breaths per minute
Following an open reduction of the tibian, the nurse notes fresh bleeding on the client's cast. Which intervention should the nurse implement?
A. Assess the client's hemoglobin to determine if the client is in shock
B. Call the surgeon and prepare to take the client back to the operating room
C. Outline the area with ink and check it q15 minutes to see if the area has increased
D. No action is required since postoperative bleeding can be expected
C. Outline the area with ink and check it q15 minutes to see if the area has increased
The nurse is with a client when the healthcare provider explains that the biopsy classifies the results as a T1N0M0 tumor. Later in the morning, the client asks the nurse, "what do these letters T1N0M0, stand for?" which response should the nurse provide first?
A. "The letters are used to predict the prognosis of the cancer or tumor."
B. "The letters stand for tumor size, node involvement and metastasis."
C. "Let me refer you to the charge nurse."
D. "Are you confused? Would you like to talk?"
B. "The letters stand for tumor size, node involvement and metastasis."
The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding? what information should the nurse provide this client?
A. The client should bottle feed and pump her breast for 3 days following immunization
B. The vaccine is given to produce maternal antibodies before lactation occurs
C. The infant will receive immunization through the mother's breast milk
D. The client should not get pregnant for 3 months after immunization
B. The vaccine is given to produce maternal antibodies before lactation occurs
In counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse take?
A. Recheck the radial pulse in thirty minutes
B. Palpate the radial pulse for thiry seconds and double the rate
C. Count the apical pulse rate for sixty seconds
D. Compare the radial pulse rate bilaterally and record the higher rate.
C. Count the apical pulse rate for sixty seconds
Which structures are located in the subcutaneous layer of the skin?
