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HESI PN COMPREHENSIVE EXIT EXAM
VERSION 7
- A nurse is performing tracheostomy care for a client who is
postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?Withdraw the catheter if the client begins coughing.Apply suction for 10 seconds.Advance the catheter 2 cm (0.8 in) after resistance is met.Use medical asepsis when performing the procedure.
- A nurse is preparing to administer a long-acting insulin to a
- A nurse is caring for an older adult client in the PACU
client who has diabetes mellitus. Which of the following actions should the nurse plan to take first?Teach the client reportable adverse effects from the medication.Check the insulin dose with another licensed nurse Administer the insulin at a 90° angle.Clean the insertion site.
following general anesthesia. Which of the following findings should the nurse report to the provider?Urine output 120 mL in 4 hr 1 / 4
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Systolic blood pressure 12 mm Hg lower than the preoperative level Audible stridor Normal sinus rhythm with an occasional premature ventricular contraction
- A nurse is preparing to administer diazepam 0.3 mg/kg IV
bolus to a toddler who weighs 22 lb and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies.Do not use a trailing zero.) 0.6
- A charge nurse is planning an educational session for staff
nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include?Choosing to donate organs can delay the timing of the child's funeral.The family can have the child an open casket without fearing that the organ donation might disfigure the childs body The family should understand that an autopsy is mandatory prior to organ donation.The nurse should introduce the option of organ donation to the parents when first discussing the child's impending death.
- A nurse manager is planning to make changes to the current
scheduling system on the unit. To facilitate the staff 's acceptance of this change, which of the following actions should the nurse manager take first?Provide information about scheduling issues to the staff 2 / 4
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Ask staff members to participate in a trial of the new scheduling system. Encourage staff to offer alternate scheduling solutions. Develop goals to implement the new scheduling system.
- A nurse is assessing a client who is receiving a blood
transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction?Bradycardia Low back pain Hypertension
Distended jugular veins
- A nurse is assessing a client who has macular degeneration.
- A nurse working in a long-term care facility is assessing an
Which of the following findings should the nurse expect?Increased intraocular pressure Floating dark spots Decreased central vision Double vision
adult client. Which of the following findings places the client at risk for development of a pressure injury?Report of persistent constipation Hgb 14 g/dL Albumin 4.2 g/dL Recent weight loss 3 / 4
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- A nurse is teaching about total parenteral nutrition (TPN)
- A nurse is caring for a client who has had nausea and
and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include?"This type of nutrition is more effective than eating by mouth." “You will receive fingersticks for blood glucose testing."TPN is a way to provide vitamins and minerals without increased calories." "Taking TPN can increase the risk of developing a latex allergy."
vomiting for the past 2 days. The nurse should identify which
of the following findings as an indication the client is experiencing fuid volume de deficit?Shortness of breath Visual disturbances Decreased BUN levels • Orthostatic hypotension
- A nurse is caring for a client who is in labor at 39 weeks of
- / 4
gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?Continue observing the fetal heart rate Assist the client to a knee-chest position.