HESI RN COMPREHENSIVE EXIT EXAM
VERSION 6
- 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 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.
- A nurse is caring for an older adult client in the PACU following general anesthesia.
Which of the following findings should the nurse report to the provider?Urine output 120 mL in 4 hr
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
- mg/mL. How many mL should the nurse administer? (Round the answer to the nearest
22 lb and is experiencing a grand mal seizure. Available is diazepam solution for injection
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
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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
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 Lowbackpain Hypertension Distended jugular veins
- A nurse is assessing a client who has macular degeneration. Which of the following
- A nurse working in a long-term care facility is assessing an adult client. Which of the
- A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a
- A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The
findings should the nurse expect?Increasedintraocularpressure Floating dark spots Decreased central vision Double vision
following findings places the client at risk for development of a pressure injury?Reportof persistent constipation Hgb 14 g/dL Albumin 4.2 g/dL Recent weight loss
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."
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 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. 2 / 3
Prepare the client for continuous internal monitoring.Prepare for an emergency cesarean birth.
- A nurse is caring for a client who requires physical therapy following discharge. Which of
the following actions should the nurse take?Initiate the referral at the time of discharge.
Have the client contact a physical therapist when feeling ready to begin therapy.Verify that insurance will pay for outpatient physical therapy.•Involve the client in selection of a physical therapy provider.
- A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of
- A nurse is teaching a group of guardians about child safety measures. Which of the
the following findings as a manifestation of vaso-occlusive crisis?Diminishedreflexes Hematuria Hyperglycemia Hearing loss
following statements by a guardian indicates an understanding of the teaching?"I will make sure my 4-year-old child wears a helmet when using a skateboard." "I should have my child avoid sun exposure between 10 am and 2 pm." "I can give my 2-year-old child a whole hotdog on a bun."
"When my infant is in the carrier, I will place it on a raised, at surface whenever possible."
- A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift
report, which of the following clients should the nurse attend to first?A client who has a temperature of 38.2° C (100.8° F) and requests a cup of ice chips
A client who is postoperative and reports a pain level of 5 on a scale from 0 to 10
A client who has voided and is ready for a bladder scan
A client who is confused and has been attempting to get out of bed
- A nurse is assessing a client who has been taking lithium carbonate for the past month to
treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority?Lethargy
Confusion
Polyuria
Fine hand tremors
- A nurse manager is on a planning committee to develop an emergency preparedness plan.
The nurse should recommend that which of the following actions takes place
Contact the triage officer.
Implement the client tracking system.
Ask the communications officer to release a press statement.
Notify the incident commander.
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