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HESI RN PHARMACOLOGY LATEST EXAM WITH DETAILED QUESTIONS AND 100% CORRECT ANSWERS.pdf
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Question- 1. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? - answer-c. Begin supplemental oxygen. Question - 2. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? - answer-d. Increase the infusion rate of Lactated Ringer's solution. Question- 3. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the
Question-4. A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) - answer-Headache and tremors Irregular heart rate pallor and diaphoresis Question-5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? - answer-d. Skin tenting occurs when the client's forearm is pinched. Question-6. After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? - answer-a. File a detailed incident report with the specific hiring facility. Question-7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective? - answer-c. Clients who incurred disease complications promptly received rehabilitation. Question-8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? - answer-d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
Question-14. The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention? - answer-c. An 18-year-old client with antisocial behavior who is being yelled at by other clients Question-15. The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms? - answer-b. Ear pain and fever. question-16. A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral atrial disease. Which question should the nurse ask the client about expected finding related to chronic arterial symptoms? - answer-b. Does the calf pain occur when walking short distances? question-17. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure? - answer-d. Experience facial swelling after eating crab. question-18. The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? - answer-b. Apply baby lotion to the skin twice daily. question-19. A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. What action should the nurse take first? - answer-d. Match ID bands of all infants and mothers on the unit.
question-20. While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? - answer-c. "Have you thought about taking your life?" question-21. A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "kill, kill." What question should the nurse ask the client next? - answer-c. "Are you planning to obey the voices?" question-22. The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? - answer-d. The client's skin on the lower legs will be intact at the next clinical visit. question-23. When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (select all that apply.) - answer-a.. Fruits without sauce c. Fresh or frozen vegetables without sauce. question-24. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse that the client is experiencing a therapeutic response to the phenytoin? - answer-c. Absence of seizure activity for the duration of treatment. question-25. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all that apply) - answer-a. Brings a heavy can close to body before lifting. b. Locks knees while preparing food on the counter.
question-32. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement? - answer-b. Ensure that the client is assigned to a room close to the nurses' station. question-33. The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client's plan of care? - answer-Ensure adequate IV and oral fluid intake. question-34. The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of preeclampsia and should be reported to the healthcare provider? (select all that apply.) - answer-Blurred vision Headache. swollen hands question-35. A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? - answer-b. Direct the nurse to change the IV tubing. question-36. A client with syndrome of inappropriate antidiuretic hormone secretion (SIDH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? - answer-Initiate seizure precautions. question-37. The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900, what nursing action is most important? - answer-Confirm that the client has been NPO since midnight.
question-38. The nurse is conducing a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? - answer-d. Cloudy opacity of the crystalline lens. question-39. A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? - answer-d. Assist him in identifying popular fast foods that are within his meal plan for diabetes. question-40. A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting his illness and is only continuing treatments because his family wants him to live. Which action should the nurse take?
question-50. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first?
question-56. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? - answer-A) Side-lying on the left with the head elevated 10 degrees question-57. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? - answer-minimal drainage into the urinary collection bag question-58. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse? - answer-C) Participate with the compressions or breathing question-59. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? - answer-B) Jugular vein distention question-60. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication - answer-Can predispose to dysrhythmias question-61. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? - answer-Pupils fixed and dilated
nursing intervention is to - answer-Administer acetaminophen as ordered as this is normal at this time question-69. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be - answer-B) Assess for dyspnea or stridor question-70. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? - answer-I went to the bathroom and my urine looked very red and it didn't hurt when I went. question-71. A middle aged woman talks to the nurse in the health care provider's office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? - answer-Fibroids that cause no problems still need to be taken out. question-72. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? - answer-A) Stay with client and observe for airway obstruction question-73. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? - answer-A) FHT 168 beats/min
question-74. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? - answer-B) "I have been coughing up foul-tasting, brown, thick sputum." question-75. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal - answer-S3 ventricular gallop question-76. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? - answer-B) The client's entire body turns a bright red color question-77. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? - answer-"The tube will remove excess air from your chest." question-78. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? - answer-Serum potassium 6 mEq/L question-79. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? - answer-C) Dyspnea question-80. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? - answer-C) Pulse oximetry of 88
foot is pale with the absence of a pulse. What should the nurse do first? - answer-A) Notify the health care provider question-88. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to - answer-Reinforce the dressing and elevate the leg question-89. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? - answer-B) Leukopenia question-90. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? - answer-Continue to monitor the rate of drainage question-91. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? - answer-Loss of pulse in the extremity question-92. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? - answer-C) Assist him to stand by the side of the bed to void
question-93. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? - answer-B) Perform a quick assessment of the client's condition question-94. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? - answer-A) Hold the tube feeding and notify the provider question-95. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must - answer-A) Apply suction for no more than 10 seconds question- 96. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to - answer-administer the medication in 2 separate injections question-97. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to - answer-D) prevent the drug from tissue irritation Skip question-98. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? - answer-improved respiratory status and increased urinary output question-99. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? - answer-C) "The medication must be continued so the fluid problem is controlled."
question-106. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? - answer-D) Application of pediculicides question-107. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? - answer-B) Potassium question-108. The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? - answer-A) Stop the infusion question-109. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? - answer-B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares question-110. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? - answer-Hemoglobin and hematocrit question-111. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? - answer-Protamine
question-112. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? - answer-D) "I always make sure to shake the NPH bottle hard to mix it well." question-113. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? - answer-Orthostatic hypotension is a common side effect question-114. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? - answer-D) Baked potato question-115. An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? - answer-B) Check the client's gag reflex question-116. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? - answer- C) Reposition every two hours question-117. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? - answer-A 79 year-old malnourished client on bed rest