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HESI EXIT V3 QUESTIONS AND ANSWERS COMPLETE SOLUTION 2018 Q&A 1-160 A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit ... for the operating room. What would be the most appropriate intervention by the nurse? The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning? The nurse is planning care for an 18 month-old child. Which action should be included in the child’s care? A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that An appropriate goal for a client with anxiety would be to While the nurse is administering medications to a client, the client states “I do not want to take that medicine today.” Which of the following responses by the nurse would be best? While caring for a client, the nurse notes a pulsating mass in the client’s peri umbilical area. Which of the following assessments is appropriate for the nurse to perform? A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age? The family of a 6 year-old with a fractured femur asks the nurse if the child’s height will be affected by the injury. Which statement is true concerning long bone fractures in children? The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)? When screening children for scoliosis, at what time of development would the nurse expect early signs to appear? A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action? A client states, “People think I’m no good, you know what I mean?” Which of these responses would be most therapeutic? A client being treated for hypertension returns to the community clinic for follow up. The client says, “I know these pills are important, but I just can’t take these water pills anymore. I drive a truck for a living, and I can’t be stopping every 20 minutes to go to the bathroom.” Which of these is the best nursing diagnosis? When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend? When observing 4-year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in? The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding? When teaching a 10-year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child? The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents’ comments? When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery after a myocardial infarction, which finding would be of greatest concern to the nurse? A 52 year-old client is being transfused with one unit of packed cells. A half-hour after the transfusion was initiated, the client complains of chills and headaches. Which action should the nurse implement first? An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which order should be questioned by the nurse? The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching? The nurse is preparing a client for discharge following in-patient treatment for pulmonary tuberculosis. Which of these instructions should be given to the client? The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse’s immediate attention? A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the treatment. What should the nurse discuss with the client as part of the teaching plan? The nurse prepares to administer eye drops to a 6-year-old child. Which of these demonstrates the correct method for the instillation of eye drops? A depressed client is experiencing severe insomnia. The health care provider orders Trazadone (Desyrel). The nurse tells the client to expect A client with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client’s symptoms of excessive hunger and thirst, what would the nurse expect the health care provider to order? The nurse is planning to administer otic drops to a 6-year-old child. Which of the following is the correct procedure? A 1-year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? Today’s prothrombin time for a client receiving Coumadin is 20 (normal range listed by the lab is 10-14). What is the appropriate nursing action? The nurse administered intravenous gamma globulin to an 18 month-old child with AIDS. The parent asks why this medication is being given. What is the nurse’s best response? The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse’s immediate attention? The nurse is teaching a client with asthma about the correct use of the Azmacort (triamcinolone) inhaler. Which of the following statements, if made by the client, would indicate that the teaching was effective? A client is admitted to the hospital because of heart failure and digoxin toxicity. At home, the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which symptom would the nurse anticipate finding on the initial assessment? The nurse admits a client with hypertension who complains of dizziness after taking diltiazem (Cardizem). Which of the following is the most important information for the nurse to assess? Which of the following classifications of medications would be most often used for clients with schizophrenia? A hospitalized 8 month-old infant is receiving digoxin for the treatment of Tetralogy of Fallot. Prior to administering the next dose of medication, the parent reports that the baby has vomited one time, just after breakfast. The heart rate is 62. What is the initial response of the nurse? A child is treated with edetate calcium disodium (Calcium EDTA) for lead poisoning. Which of these should the nurse assess first ? The nurse is assessing a client who has taken haldol (Haloperidol) for several months. Which of the following is a side effect of this medication and must be reported immediately to the health care provider? The nurse is caring for a client with renal calculi. Which health care provider order would be a priority? A client with angina has been instructed about the use of sublingual nitroglycerin. Which of the following statements made to the nurse indicates a need for further teaching? The nurse is teaching the administration of albuterol inhalation to an adult with asthma. Which of the following demonstrates proper teaching? A hospitalized 8 month-old is receiving gentamicin (Cidomycin). In monitoring the infant for drug toxicity, the nurse should review which laboratory results first? A client who is receiving chemotherapy through a central line is admitted to the hospital with a diagnosis of sepsis. Which of the following nursing interventions should receive priority? The nurse is caring for a client with Parkinson’s disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor? The nurse is caring for a child receiving albuterol (Proventil) for asthma. The parents ask the nurse why their child is receiving this medication. Which explanation is correct? The nurse prepares to give a one year-old child an intramuscular injection. Where is the best site for this injection? The nurse is administering albuterol (Proventil) to a child with asthma. Which of the following assessments by the nurse indicate the need for an adjustment of the medication? To which of the following nursing home residents could the nurse safely administer tricyclic antidepressants without questioning the health care provider’s order? The nurse is teaching a client about precautions with Coumadin. The nurse should instruct the client to avoid foods with excessive amounts of which nutrient The nurse is caring for a 15 month-old child with a first episode of otitis media. Which of the following interventions should the nurse include in instructions to the child’s parents? The nurse is caring for an 81 year-old client with colorectal cancer. The client’s pain has been managed until now with acetaminophen with codeine. Because of increased pain, intravenous morphine is added. What should the nurse recognize about the validity of this order? Before administering digoxin (Lanoxin) to a client, which of the following nursing assessments is a priority? When teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that which of these is the most common side effect? What would the nurse expect to see in a client who is experiencing symptoms of tardive dyskinesia? The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which of the following must be emphasized? The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? The nurse in the same day surgery unit assigns the unlicensed assistive personnel (UAP) to give a 1000 ml soap solution enema (SSE) to a client scheduled for an abdominal hysterectomy. Which statement by the nurse is most appropriate? An RN from the women’s health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse? Which client data should the nurse act upon when a home health aide calls the nurse from the client’s home to report these items? A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)? A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate? A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which o staff members should the charge nurse assign the client? Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to ambulate a client for the first time after a colon resection? A charge nurse working in a long term care facility is making out assignments. Which assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires intervention by the supervisor? Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)? Which one of these tasks can be safely delegated to a PN? The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP? Which of these clients would be most appropriate to assign to a PN? A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)? Which of these clients would be appropriate to assign to a PN? Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP? During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence? An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions? The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? The RN delegates the task of taking vital signs of all the clients on the medical- surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client’s blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client’s left arm. Which of these statements is most accurate? As the RN responsible for a client in isolation, which can be delegated to the PN? The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)? The charge nurse on a cardiac step-down unit makes assignments for the team consisting of an RN, a PN, and an unlicensed assistive person. Which client should be assigned to the PN? When walking past a client’s room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention? A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements? A client experiences intense anxiety after the home was destroyed by a fire. The client escaped from the fire with only minor injuries. The nurse knows that the most important initial intervention would be to: An elderly client with tuberculosis has difficulty coughing up secretions for a sputum specimen. Which nursing action is appropriate? The nurse is caring for a 16 year-old client with femur fracture14 hours after surgery. Assessment findings include tachycardia, increased shortness of breath, a temperature of 100.2 degrees Fahrenheit, complaints of feeling anxious, and oxygen saturation level of 88%. In immediately notifying the provider of these findings, the nurse recognizes the client is at risk for The client referred for a mammography questions the nurses about the cancer risks from radiation exposure. What is the appropriate response by the nurse? On admission to the ambulatory surgery unit, the nurse notices the client’s painted finger nails. On reviewing the pre-op orders, the nurse notes that pulse oximetry has been ordered. Which statement by the nurse is appropriate? The nurse is removing a fecal impaction on a 75 year-old client. It is most important that the nurse remember that When taking the client’s blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. Which action should the nurse take first? The client with multiple sclerosis has an order to change the nasogastric tube. To promote safety when removing the tube, the nurse should A client is being discharged home today, and will be taking K-dur 20mEq per day by mouth. The nurse should reinforce that potassium levels will be decreased by A client has just returned from the Post-Anesthesia Care Unit (PACU) to the surgical unit after a cholecystectomy. When initial vital signs are taken the nurse notes a temperature of 94.8 degrees Fahrenheit. Which first nursing action is appropriate? The client with amyotrophic lateral sclerosis is scheduled for 160 ml of enteral feeding as a bolus every 4 hours. Before flushing with water the nurse aspirates the feeding tube contents and gets back 180 ml of feeding. What is the next appropriate nursing action? The nurse is inserting a Foley catheter into the bladder of a female adult client. The nurse slips the catheter into an opening for four-5 inches and no urine is obtained. The most probable reason for this is that After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased prior to moving the body. The appropriate response by the nurse is The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action? A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are complaining. As a change agent, the nurse manager should first The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication? In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube? The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter? A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action? To obtain data for the nursing assessment, the nurse should: The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate? A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse? The nurse is teaching diet restrictions for a client with Addison’s disease. The client would indicate an understanding of the diet by stating A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take? During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client’s knees. The best action for the nurse to take is to A client with considerable pain asks: “What is your opinion regarding acupuncture as a drug-free method for alleviating pain?” The nurse responds, “I’d forget about it as those weird non-Western treatments can be scary.” The nurse’s response is an example of A 9-year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child’s greatest fear? A nurse arranges for an interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to The nurse is planning care for a 2-year-old hospitalized child. Which of the following will produces the most stress at this age? Which statement describes strategies that help build personal power in an organization? A 24-year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have A mother telephones the clinic and says “I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding.” The nurse’s best response would be which of these? Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child’s neck. The parents refuse. The nurse understands that the parents may be concerned about Which statement describes the use of a decision grid for decision making? The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown? Dual diagnosis indicates that there is a substance abuse problem as well as a Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy? The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis? The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition? What is the major developmental task that the mother must accomplish during the first trimester of pregnancy? During the two-month well-baby visit, the mother complains that formula seems to stick to her baby’s mouth and tongue. Which of the following would provide the most valuable nursing assessment? After successful alcohol detoxification, a client remarked to a friend, “I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink.” The client’s belief that he needs alcohol indicates his dependence is primarily A nurse is caring for a client with peripheral arterial insufficiency of the lower extremities. Which intervention should be included in the plan of care to reduce leg pain? A diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test: The nurse is speaking to a group of parents and school teachers of children about care for children with rheumatic fever. It is a priority to emphasize that A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity? A mother calls the clinic, concerned that her 5 week-old infant is “sleeping more than her brother did.” What is the best initial response? The nurse is caring for a client with COPD who becomes dyspneic. The nurse should The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse’s immediate attention? A 6-year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would the nurse’s best response to this request? Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage? A nurse aide is taking care of a 2-year-old child with Wilm’s tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements? A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis? A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is The nurse sees a substance-abusing client occasionally in the outpatient clinic. In evaluating the client’s progress, the nurse recognizes that the most revealing resistant behavior is A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor? Parents of a 6 month old breastfed baby ask the nurse about increasing the baby’s diet. Which of the following should be added first? A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to A victim of domestic violence states, “If I were better, I would not have been beaten.” Which feeling best describes what the victim may be experiencing? A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being “too sick to return to work.” The client is diagnosed as having a somatoform disorder. In formulating a plan of care, the nurse must consider that the client’s behavior Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child? The nurse is planning care for a client during the acute phase of a sickle cell vaso- occlusive crisis. Which of the following actions would be most appropriate? Following surgery for placement of a ventriculoperitoneal (VP) shunt as a treatment for hydrocephalus, the parents question why the infant has a small abdominal incision. The best response by the nurse would be to explain that the incision was made in order to The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship? A child is sent to the school nurse by a teacher who has a written note that Fifth’s disease is suspected. Which characteristic would the nurse expect to find? Delirium tremens could best be described as An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask? The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem? The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68-year-old client with a diagnosis of congestive heart disease. Which finding is most likely to occur? While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior? The nurse should initiate discharge planning for a client The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client? When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is the most effective intervention? [Show More]

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