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RN HESI 799 Exit Exam Prep 2024: High-Yield Study
Guide with Realistic Questions & Proven Success
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The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan? a. Monitor for an elevated temperature b. Measure the abdominal girth daily c. Report the onset of sclera jaundice d. Keep a record of daily urinary output - - CORRECT ANS- - a. Monitor for an elevated temperature Rationale: The client should be instructed to monitor or elevated temperature because immunosuppressant agents, which are prescribed to reduce rejection after transplantation, place the client at risk for infection. The client should recognize sign of liver rejection, such as sclera jaundice and increasing abdominal girths, but fever may be the only sign of infection. A is not as important and monitoring for signs of infection. After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? a. Initiate intravenous fluid as prescribed b. Notify the HCP of the need to reposition the catheter c. Remove the catheter and apply direct pressure for 5 minutes.
d. Secure the catheter using aseptic technique - - CORRECT ANS- - Initiate intravenous fluid as prescribed Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous fluid can be started. A and B are not indicated at this time. The catheter should be secure immediate following insertion (C) A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? a. The client has asymmetrical chest wall expansion b. The clients complain of pain at the insertion site c. The client chest's x-ray indicates decreased pleural effusion d. The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26 - - CORRECT ANS- - a. The client has asymmetrical chest wall expansion Rationale: A potential complication of thoracentesis is a pneumothorax. The symptoms of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the local anesthetic effects "wear off" B is a desired result of thoracentesis and C is within normal limits. A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first? a. Determine the client's responsiveness and respirations b. Bring the crash cart to the room to defibrillate the client.
The nurse is conducting health assessments. Which assessment finding increases a 56 year-old woman's risk for developing osteoporosis? a. Body mass index of (BMI) of 31 b. 20 pack-year history of cigarette smoking c. Birth control pill usage until age 45 d. Diabetes mellitus in family history - - CORRECT ANS- - b. 20 pack-year history of cigarette smoking Rationale: Cigarette smoking (2 packs/day x 10 years = 20 packs-year) increases the risk of osteoporosis. BMI of 30 or greater falls in the category of obesity which increase weight bearing that is protective against osteoporosis. C contain estrogens and are also protective against development of osteoporosis. D is not related to the development of osteoporosis. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider? a. Decreased white blood cell count b. Pruritus and muscle aches c. Elevated liver function tests d. Vomiting and diarrhea - - CORRECT ANS- - c. Elevated liver function tests Rationale: Valacyclovir is an antiviral agent of acyclovir which is used in therapy of herpes simplex and varicella-zoster virus infections (shingles). Valacyclovir has been associated with rare instances mild, clinically apparent liver injury.
A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? a. Review the heart rhythm on cardiac monitors b. Check urinary catheter for obstruction c. Auscultated bilateral breath sounds d. Give PRN dose of lorazepam (Ativan) - - CORRECT ANS- - c. Auscultated bilateral breath sounds Rationale: Restlessness often results from decreased oxygenation, so breath sounds should be assessed first. Giving an anxiolytic such as lorazepam, might be indicated but first the client should be assessed for the cause of the restlessness. An obstruction in the urinary drainage system can cause a distended bladder that may result in restlessness, but patent airway is the priority intervention. The client should be assessed before evaluating the cardiac rhythm on the monitor. The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately? a. headache, photophobia, and nuchal rigidity b. high fever, skin rash, and a productive cough c. nausea, vomiting, and poor skin turgor d. malaise, fever, and stiff, swollen joints - - CORRECT ANS- - headache, photophobia, and nuchal rigidity Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal infection, so this client should immediately be referred to the health care provider. AC D do not have priority of B
The nurse observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What action should the nurse perform first? A. determine the client's blood pressure and apical pulse B. observe the amount of urine in the clients urinary drainage bag C. obtain a pulse oximeter to assess the client's oxygen saturation D. review the medication record for recently administered medications - - CORRECT ANS- - B. observe the amount of urine in the clients urinary drainage bag. Rationale: If blood clots are present, the nurse should first determine if urinary output has become obstructed by observing the amount of urine in the urinary drainage bag (B) Continuous bladder irrigation is performed to prevent blood clots that may form and obstruct the outflow of urine The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation? a. Tell the UAP to offer more choices during the personal care to prevent anxiety b. Meet with the UAP later to role model more assertive communication techniques c. Assume care of the client to ensure that effective communication is maintained. d. Affirm that the UAP is using an effective strategy to reduce the client's anxiety. - - CORRECT ANS- - d. Affirm that the UAP is using an effective strategy to reduce the client's anxiety. Rationale: Reduction is an effective technique is managing the anxiety of client with Alzheimer's disease, so the nurse should affirm the UAP is using an effective strategy (A). Nurse assertive communication and offering more choices (B) may increase... an agitation (C) is not indicated since the UAP is using redirection, an effective strategy.
An older female who ambulates with a quad-cane prefers to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply) a. Move personal items within client's reach b. Lower bed to the lower possible position c. Raise all bed rails when the client is resting d. Give directions to call for assistance e. Assist client to the bathroom in 2 hours. f. Encourage the use of the wheelchair - - CORRECT ANS- - a. Move personal items within client's reach b. Lower bed to the lower possible position d. Give directions to call for assistance e. Assist client to the bathroom in 2 hours. Rationale: A client who needs assistive devices, such as quad-cane is at risk for falls. Precautions that should implement include ensuring that personal items are within reach the bed is in the lowest position and directions are given to call assistance to minimize the risk for falls. Frequently assisting the client to the bathroom help ensure this client does not go the bathroom by herself, thereby decreasing the possibility of falling. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? a. Evaluate the client's ability to use an incentive spirometer b. Monitor the amount of drainage from the client's incision c. Observe both lower extremities for redness and swelling
e. Cross legs at knee but not at ankle - - CORRECT ANS- - a. Avoid prolonged standing or sitting b. Use a recliner for long periods of sitting c. Continue wearing elastic stockings The nurse has received funding to design a health promotion project for AfricanAmerican women who are at risk for developing breast cancer. Which resource is most important in designing this program? a. A listing of African-American women so live in the community b. Participation of community leaders in planning the program c. Morbidity data for breast cancer in women of all races d. Technical assistance to produce a video on breast self-examination. - - CORRECT ANS- - Participation of community leaders in planning the program The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? a. Lip smacking and frequent eye blinking b. Shuffling gait and stooped posture c. Rocks back and forth in the chair d. Muscle spasms of the back and neck - - CORRECT ANS- - d. Muscle spasms of the back and neck A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first?
a. Examine the victim's body surfaces for arterial bleeding b. Stabilize the victim's neck and roll over to evaluate his status c. Return to the car to call emergency response 911 for help d. Open the airway and initiate resuscitative measures - - CORRECT ANS- - b. Stabilize the victim's neck and roll over to evaluate his status During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings' incidence of otitis media? a. Varicella Virus Vaccine Live b. Hemophilic Influenza Type B (HiB) vaccine c. Pneumococcal vaccine d. Palivizumab vaccine for RSV - - CORRECT ANS- - b. Hemophilic Influenza Type B (HiB) vaccine The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.) 1.9 - - CORRECT ANS- - 1. Rationale: 38/20x1=1.9 m The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse?
d. No injuries refer to soft restrains occur - - CORRECT ANS- - b. Maintain effective breathing patterns Rationale: Basic airway management (B) is the priority. Pain management (A), risk of infection (C), and prevention of injury (D) do not have the same priority as (C) The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? a. High salt can damage the lining of the blood vessels b. Too much salt can cause the kidneys to retain fluid c. Excessive salt can cause blood vessels to constrict d. Salt can cause information inside the blood vessels - - CORRECT ANS- - b. Too much salt can cause the kidneys to retain fluid Rationale: Excessive salt intake can contribute to primary hypertension by causing renal salt retention which influence water retention that expands blood volume and pressure (ACD) are not believed to contribute to primary hypertension. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image). right upper chest, left midaxillary - - CORRECT ANS- - right upper chest, left midaxillary In assessing a pressure ulcer on a client's hip, which action should the nurse include? a. Determine the degree of elasticity surrounding the lesion
b. Photograph the lesion with a ruler placed next to the lesion c. Stage the depth of the ulcer using the Braden numeric scale d. Use a gloved finger to palpate for tunneling around the lesion - - CORRECT ANS- - b. Photograph the lesion with a ruler placed next to the lesion Rationale: An ulcer extends into the dermis or subcutaneous tissue and is likely to increase in size and depth, so assessment should include photograph with measuring device to document the size of the lesion. A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care? a. Implements decisions about future hospices services within the next 3 months. b. Maintaining pain level below 4 when implementing outpatient pain clinic strategies. c. Request home health care if independence become compromised for 5 days. d. Arranges for short term counseling stressors impact work schedule for 2 weeks. - - CORRECT ANS- - b. Maintaining pain level below 4 when implementing outpatient pain clinic strategies. Rationale: An outpatient pain clinic provides the interdisciplinary services needed to manage chronic pain. Also, the client has a terminal disease and is being discharge home, hospice and health care are not indicating currently. Short term counseling is not an option. A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement? a. Auscultate all quadrants of the abdomen.
c. Review the client's record regarding social interactions d. Reassure the client of her family's love for her - - CORRECT ANS- - a. Ask the client when a family member last visited her. A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? a. creatinine clearance 25 mL/ minute b. calcium 9 mg/dl c. hemoglobin 12 grams/dl d. partial thromboplastin time (PTT) 30 seconds - - CORRECT ANS- - a. creatinine clearance 25 mL/ minute The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement? a. Observe the wound for dehiscence b. Teach the client to splint the incision while coughing c. Assess the skin surrounding the wound for maceration d. Obtain a culture of the wound drainage. - - CORRECT ANS- - a. Observe the wound for dehiscence A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status? a. A 24-hour diet history b. History of a recent weight loss
c. Status of current petite d. Condition of hair, nails, and skin - - CORRECT ANS- - d. Condition of hair, nails, and skin Rationale: The assessment of hair, nails and skin is most indicative of long-term nutritional status, which is important in the healing process. The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention? a. A young adult with Crohn's disease who reports having diarrheal stools b. An older adult with type 2 diabetes whose breakfast tray arrives 20 minutes late. c. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping. d. A teenager who reports continued pain 30 minutes after receiving an oral analgesic. - - CORRECT ANS- - c. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping Rationale: The nurse should immediately assess the child whose infusion pump is alarming during chemotherapy administration because infiltration of a caustic agent can cause tissue damage and children are at greater risk for fluid volume imbalance. Diarrhea is a common occurrence for Crohn's disease. Late consumption of food for a diabetic is of concern, but 20 minutes late is usually not life-threatening. Treatment of pain is most important but has been only 30 mints since the client was medicated and this issue can be assessed in 10 mints or delegated to another nurse. The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first? a. Attached de IV tubing to the central line. b. Check the TPN solution for cloudiness
A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit?
- Discuss the importance of continuing the usual at-home activities
- Encourage the family to plan daily activities to keep the client busy
- Have friends and family visit the client at a welcome party.
- Instruct family to monitor the client's choice of television programs. - - CORRECT ANS- -
- Discuss the importance of continuing the usual at-home activities Rationale: Week-end pass are schedules to help the client ease back into the family's routine, so the client can back to normal activities. When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first? a. Include the family in client's care b. Request the chaplain's presence c. Ask the family to identify a specific spokesperson d. Page the healthcare provider to speak with family. - - CORRECT ANS- - c. Ask the family to identify a specific spokesperson A client with pneumonia has an IV of lactated ringer's solution infusing at 30ml/hr current labor....sodium level of 155 mEq/L, a serum potassium level of 4mEq/L.... what nursing intervention is most important? a. Provide a high-potassium snack, such as bananas. b. Obtain a prescription to increase the IV rate
c. Administer the next scheduled dose of antibiotic d. Review the report of the most recent chest x-ray. - - CORRECT ANS- - b. Obtain a prescription to increase the IV rate After teaching a male client with chronic kidney disease (CKD) about therapeutic diet... which menu of foods indicates that the teaching was effective? Select all that apply a- A slice of whole grain toast b- Half cup of black beans c- A ham and cheese sandwich d- A bowl of cream of wheat e- Two bananas. - - CORRECT ANS- - a- A slice of whole grain toast d- A bowl of cream of wheat Rationale: Patient with CKD have elevated serum potassium, sodium and protein levels. A and D are low in potassium, sodium and protein, Beans are rich in proteins. C are high in sodium and potassium and E are rich in potassium. A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM? a- Immune antibodies attack pancreatic beta cells resulting in no insulin b- The body cells develop resistance to the action of insulin. c- Body organs produce less insulin and more glucagon d- The liver produces excess glucose in response to excess glycotrophic hormones - - CORRECT ANS- - d. The body cells develop resistance to the action of insulin
