HESI PN COMPREHENSIVE EXIT EXAM

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HESI PN COMPREHENSIVE EXIT EXAM

VERSION 12

• A client begins treatment with phenytoin (Dilantin). Which following should

the nurse reinforce as a measure to help minimize possible adverse effects of this medication?

• Performing daily gum massage

• A nurse who is facilitating a support group notices that one client in the group is

extremely talkative, to the point where others in the group have difficulty sharing their own ideas. Which of the ff. strategies should the nurse use to facilitate the group process with this client?

• Speak privately to the client about this behavior.
• The partner of a client who died from leukemia tells a nurse, “It’s so unfair that

God took him from me. I just can’t live without him.”. Which of the following actions by the nurse is the priority?

• Ask the client she has had suicidal thoughts.
• A nurse is preparing to remove a client’s peripheral IV catheter. Which of the

following actions should the nurse plan to take?

• Maintain the catheter parallel to the vein when withdrawing the catheter.
• A nurse is reinforcing teaching to the parents of a newborn who has a new

prescription for nystatin (Mycostatin) for oral candidiasis. Which of the following should the nurse include in the teaching?

• Instill the medication 1 hr. after feeding.
• A nurse is reinforcing teaching about an IV urography (IVP) with the parent of a

3yr. old child. Which of the ff. statements indicates the parent understands the teaching?

• My child will need to have a soapsuds enema before this procedure.
• A nurse is reinforcing teaching with the parent of a school-age child who has

nephrotic syndrome with peripheral edema. Which of the ff. statements by the parent indicates understanding of the teaching?

• I will provide a low-sodium diet for my child.
• A nurse is caring for a client who is on complete bed rest and is unable to

change positon in bed without assistance. The nurse delegates the task of repositioning the client every 2 hr. to an assistive personnel(AP). Which of the ff. is an appropriate method to ensure that the AP has performed the task correctly?

• Check that the client is in a new position every 2hr.
• A newly hired nurse discovers that some medication doses provided on a

client’s medication record have not been updated since yesterday. Coworkers admit that new changes in the medication orders have not been processed yet, but they advise the nurse to administer the new prescriptions anyway. The nurse should notify which of the ff.? 1 / 2

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• The nurse manager.
• A registered nurse and a licensed practice nurse (LPN) on a medical–surgical

unit are collaborating to provide care for a group of clients. The LPN should recognize that which of the ff. tasks are not within the LPN scope of practice?

• Develop a plan of care for a client who requires bladder training.
• Which of the ff. should a nurse recognize as indicative of a positive client

response to systematic desensitization for treatment of a phobia?

• The client remains relaxed when thinking of the phobia.
• A nurse in a long-term care facility is reviewing standard precaution guidelines

with an assistive personnel(AP). The nurse should instruct the AP that which of the ff. should be used to clean up a blood spill?

• Chlorine bleach solution.
• A nurse is caring for a client who is 3 days postoperative ff. a transurethral

resection of the prostate and has an indwelling urinary catheter. Which of the ff.findings should the nurse expect?

• Yellow urine with red sediment.
• A nurse is preparing to administer cephalexin (Keflex) to a client when he

states, “ I just remembered that I have an allergy to penicillin. “Which of the ff.actions should the nurse take?

• Call the provider who prescribed the medication.
• A nurse is observing a newly licensed nurse who is providing tracheostomy

care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the ff. solutions to clean the inner cannula?

• Hydrogen peroxide.
• A nurse is working with an interpreter to explain a diagnostic procedure to a

client who does not speak English. Which of the ff. actions should the nurse take?

• Ensure the interpreter is culturally compatible with the client.
• A client 12 hr. postoperative cholecystectomy was given morphine 10mg

intravenously at 0700. The nurse marking rounds at 0720 should recognize which of the ff. as an adverse effect of the medication?

• Respiratory rate 10/min
• A nurse is inserting an indwelling catheter into a female client who has urinary

retention. After urine is seen in the tubing, which of the ff. actions should the nurse take next?

• Advance the catheter 2.5 to 5 cm.
• A nurse is administering morning medication to clients on the unit. A client

questions the nurse regarding a medication that she does not recognize. Which of the ff. nursing interventions should the nurse take first?

• Verify the prescription in the client’s medical record.
• A nurse is reinforcing teaching regarding prenatal discomfort to a client who is

at 20 weeks of gestation. Which of the ff. statements made by the client indicates an understanding of the teaching?

• I will wear a supportive bra overnight.
• A nurse is caring for a client who has leukemia and is experiencing stomatitis

ff. treatment. Which of the ff. is an appropriate diet selection by the nurse?

• Oatmeal and apple sauce
• A nurse is reinforcing teaching for a client who has coronary artery disease and

is taking low-dose aspirin daily. The nurse should reinforce that this medication

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