HESI LEVEL 1 PRACTICE EXAM LATEST (Already graded A) The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assess... ing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10% dextrose and water at 54 ml/hour. D. Obtain a stat blood glucose level and notify the healthcare provider. -✔✔ C A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement? A. Notify the healthcare provider of the measurement. B. Quiet the child and retake the blood pressure. C. Ask the parent if the child has a history of hypertension. D. Document the finding and recheck in 4 hours. -✔✔ B The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide? A. The kidneys and renal function are not fully developed. B. Warmth promotes sleep so the infant will grow quickly. C. A large body surface area favors heat loss to the environment. D. The thick layer of subcutaneous fat is inadequate for insulation. -✔✔ C What action by the nurse demonstrates culturally sensitive care? A. Asks permission before touching a client. B. Avoids questions about male-female relationships. C. Explains the differences between Western medical care and cultural folk remedies. D. Applies knowledge of a cultural group unless a client embraces Western customs. -✔✔ A A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A. Help the client to accept the final stage of life. B. Assist and support the client in establishing short-term goals. C. Encourage the client to make future plans, even if they are unrealistic. D. Instruct the client's family to focus on positive aspects of the client's life. -✔✔ B A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment? A. "What is your daily calorie consumption?" B. "What vitamin and mineral supplements do you take?" C. "Do you feel that you are overweight?" D. "Will a clear liquid diet be okay after surgery?" -✔✔ B The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? A. A 10-year-old who was burned by a camp fire earlier today. B. A 70-year-old who has a postoperative infection from a surgery one week ago. C. A 23-year-old woman who sprained her knee while bicycling. D. A 55-year-old woman who has had moderate low back pain for three months. -✔✔ D A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. -✔✔ C In evaluating client care, which action should the nurse take first? A. Determine if the expected outcomes of care were achieved. B. Review the rationales used as the basis of nursing actions. C. Document the care plan goals that were successfully met. D. Prioritize interventions to be added to the client's plan of care. -✔✔ A A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator. -✔✔ D An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 mL of warm water and 5 mL of castile soap. C. Reposition in a Sims' position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level. -✔✔ C A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement? A. Remove the object impaled in the eye and then apply a regular eye patch. B. Place an ice bag over the eye until the healthcare provider is seen. C. Irrigate the affected eye copiously with a cool sterile saline solution. D. Apply a Fox shield to the affected eye and any type of patch to the other eye. -✔✔ D [Show More]
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