HESI EXIT RN EXAM 2022 V5 - REAL 160 Questions and answers DOWNLOAD TO SCORE A (RATED 100%)

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HESI EXIT RN EXAM 2022 V5 - REAL 160 Questions and answers DOWNLOAD TO SCORE A (RATED 100%) HESI EXIT RN EXAM 2022 V5 - REAL After placing a 36- week- gestation newborn in an isolette a... nd drying the infant with several blankets, what should the nurse implement next? - ANS Remove the wet blankets and linen from the isolette A client in the third trimester of pregnancy complains of frequent nasal stiffness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement? - ANS Record the respiratory finding in the clients chart as normal A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings. His appetite is poor and he often refuses oral intake of solids and liquids. For the past several days he has been unable to get out of bed. Which action should the hospice nurse implement? - ANS Instruct family to offer client only soft bland foods A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy test and ultrasound were negative, so an exploratory laparotomy was completed during the night. When coffee ground materials is observed in the drainage from the nasogastric tube (NGT), which intervention should the nurse implement? - ANS Verify correct placement of the nasogastric tube The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports of the abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to evaluate the clients clinical recovery? - ANS Lipase While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL of dark red fluid has drained from the nasogastric tube in the last hour. Which action should the nurse take first? - ANS take vital signs The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients? - ANS Avoid large crowded areas during the colder months of the year The mother of a one-moth-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond? - ANS Position the infant on the stomach occasionally when awake and active A woman is brought to the labor and delivery unti after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. Which action should the nurse perform first? - ANS Perform a fundal massage A client has a new prescription for the maximum recommended dosage of pipercillin/tazobactam for nosocomial pneumonia. The nurse should report which laboratory finding to the healthcare provider before administering the prescribed dose? - ANS Decrease serum creatine A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing and has a severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L (24mmol/L). Which assessment finding warrants immediate intervention by the nurse? - ANS Fruity breath When performing postural drainage on a client with Chronic Obstructive Pulmonary disease (COPD), which approach should the nurse use? - ANS Explain that the client may be placed in five positions A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a "do not resuscitate" (DNR) prescription. Which action should the nurse take? - ANS Initiate an ethics committee review In observing a clients face, which assessment finding requires the most immediate intervention by the nurse? - ANS Oral mucosa is cyanotic Blue lips The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which action should the nurse take in response to the finding? - ANS Complete a thorough neurological assessment Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter? - ANS Ensure continued sterility of the specimen container The home health nurse observes an older client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. Which action should the nurse take? - ANS Hold the chair A client with cancer complains of fever, chills, malaise, and headache following administration of a colony-stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu like symptoms? - ANS Monitor lab values for an increase in WBCs Which laboratory value should the nurse review prior to administering the initial dose of a statin medication? - ANS Serum liver enzymes Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure? - ANS I have a headache that gets worse when I sit up The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a prescription for clonidine 0.2 mg PO taken twice daily. Which action should the nurse take? - ANS Advise to sit up slowly from a reclining position A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history form the child's mother, the recent occurrence of what illness is most significant? - ANS Sore throat Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is the best follow-up action by the nurse? - ANS Review with the client the need to avoid foods that are rich in milk and cream The nurse assesses a client with cirrhosis and find 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? - ANS hyperaldosteronism caused by decreased degradation of the hormone by the liver. The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe, colicky abdominal pain, nauseas, vomiting, and abdominal distention. Which pathophysiological mechanism supports the client's clinical presentation? - ANS A weakened diaphragm with high abdominal pressure An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide to this client? - ANS Maintain prescribed eye drop regimen The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? - ANS A new graduate should be able to complete a pre-procedural checklist and get this client to the catheterization lab. Penicillin G procaine 240,000 units intramuscularly is prescribed for a 4-year-old child who has streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2mL. How many mL should the nurse administer? - ANS 0.4 D/HX2ml A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? - ANS knee chest position [Show More]

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