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HESI PN COMPREHENSIVE EXIT EXAM
VERSION 14
**A client is postoperative following a lumbar discectomy and is having difficulty voiding. The nurse should recognize that which of the following medications place the client at risk for urinary retention?Ketorolac Hydromorphone (Dilaudid) Bethanechol (Urecholine) Tobramycin (Nebcin)
**A nurse is caring for an older adult client in a long-term care facility who is disoriented and continues to get out of bed without assistance. Which of the following images indicates the nurse is using an appropriate intervention to minimize the risk of injury due to a fall?D
**A practical nurse (PN) on medical-surgical unit is beginning her shift and is working with a registered nurse (RN) and an assistive personnel (AP). The PN should expect to be assigned which of the following tasks?Teach a client who has a new diagnosis of diabetes mellitus how to self-administer insulin.Create a plan of care for a newly admitted client.Obtain a stool specimen from a client who has ulcerative colitis---- Administer an NG tube feeding to a client who had a stroke
**A nurse on an acute mental health unit observes a client who begins to speak loudly in the common room, saying that he can’t hear the TV. Which of the following is an appropriate response by the nurse?You will need to go to your room until you can calm down okay The TV is loud enough for everyone to hear it You are being inconsiderate. Please stop talking so loudly Let’s go to another room to talk about what is upsetting you
**A client tells a nurse that he would like to observe kosher dietary laws. The nurse should recognize which of the following?A vegetarian diet is the preferred diet Dairy products are served separately from meat Fasting during daylight is required during a month-long holiday Fish with scales and fins should not be eaten
**A nursing unit receives new glucose monitoring equipment from staff development with the promise that in-service education will be given soon. Which of the following instructions should the nurse give to the assistive personnel (AP) who is preforming glucose monitoring on the unit?Contact the staff development department for instruction Continue using the current glucose monitors Check for accuracy and proper functioning of the new monitor Read the instruction manual before attempting to use the new monitor 1 / 3
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**Which of the following should the nurse document as an indication of the IV infiltration in a client’s forearm?Redness along vein Tissue sloughing at the site Forearm that is warm to the touch Pallor surrounding the infusion site
**A client requests information about advanced directives. Which of the following is the appropriate response by the nurse?Advanced directives are written instructions regarding end of life care Advanced directives provide education on palliative care issues Advanced directives require the provider’s approval before changes can be implemented Advanced directives help determine legal competency
**A nurse is caring for a client who is on telemetry. Which of the following ECG findings should the nurse report to the charge nurse?One P wave prior to each QRS complex PR interval 0.24 seconds QRS duration 0.06 seconds Ventricular rate 75/min
**A nurse is checking the reflexes of a newborn. Which of the following techniques should the nurse use to elicit the Babinski reflex?Startle the infant by clapping hands Stroke the sole of the infant’s foot upward and toward the great toe Hold the infant upright and allow one foot to touch the table’s surface Place an object in the palm of the infant’s hand
**A charge nurse in a long-term care facility notices an assistive personnel’s (AP) repeated failure to provide oral care for clients. Which of the following actions should the nurse take?Provide oral care for clients after the AP has completed other care Develop an educational session about the importance of oral care for all Aps Discuss the unacceptable behavior with the AP while reinforcing expectations Suspend the AP for 3 days pending disciplinary action
**A nurse is caring for a client who has terminal cancer. Which of the following statements by the client’s family should indicate the nurse that they are coping with their situation?Dad I remember the time we all went to the lake fishing Dad I truly believe that it’s not your time to leave us I feel like I don’t know what to do anymore I think we need to concentrate on whose house we plan to meet at for our holiday get-together
**A nurse is performing a dressing change for a client who had abdominal surgery 5 days ago. The nurse notes organs protruding from the incision. Which of the following actions should the nurse take?Apply an abdominal binder Have the client lie flat in bed.Cover the exposed area with sterile, saline-soaked dressing Place gentle pressure on the exposed organ with sterile gauze
**A nurse in a skilled nursing facility is caring for a client who is receiving warfarin (Coumadin) therapy following a total hip replacement. An assistive personnel reports a positive guaiac. Which of the following laboratory values should the nurse report to the provider?Hematocrit 40% International normalized ratio of 4.5 2 / 3
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Hemoglobin 15 g/dL-- Prothrombin time 18 seconds
** A nurse is reinforcing teaching with a client who has hypertension and is beginning medication therapy with captopril (Capoten). Which of the following over-the-counter medications should the nurse instruct the client to avoid?Acetaminophen (Tylenol) Diphenhydramine Ibuprofen (Advil) Guaifenesin (Robitussin)
**A nurse is reinforcing teaching for a client who is in her first trimester of pregnancy. Which of the following physiological changes should the nurse instruct the client to expect during the first trimester?Leukorrhea Shortness of breath Pedal edema Perineal pressure ** A nurse is collecting data from a client who has a peptic ulcer disease. Which of the following should the nurse identify as the priority finding?Gnawing epigastric pain Heartburn Regurgitation Hematemesis
**A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following behavioral indications should the nurse expect?Dependence Euphoria Memory Loss Hypervigilance
**A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse identify as a delusion?My doctor’s glasses have lasers that will burn holes in my brain if I look at him The movie had an explosion. I once drove a green truck. Where is the ketchup The voice keeps telling me to go kick the table over. Why won’t it stop I can’t sit here because the purple monkey on the ceiling will jump on me
**A nurse is caring for a client who sustained a broken leg while assisting other from a structural fire.The client states I am glad those people were saved but I sure wish I was not hurt. Which of the following is an appropriate response by the nurse?You are a real hero. I am sure that makes your injuries worthwhile It is difficult to experience personal injuries for whatever reason Things will get better before long Let’s talk about this later when we have more time
**A nurse is reinforcing teaching for a client who has a new prescription for lithium carbonate (Lithobid). Which of the following instructions should the nurse include?Eliminate all foods containing tyramine Drink 2 to 3 liter of fluid each day Take lithium carbonate on an empty stomach Reduce your daily sodium intake to 1,000 mg
**A nurse in a provider’s office is reinforcing teaching with a client who is receiving peritoneal dialysis via a newly inserted catheter. For which of the following should the nurse instruct the client to
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