HESI RN COMPREHENSIVE EXIT EXAM

HESI RN COMPREHENSIVE EXIT EXAM

VERSION 7

Post-operative care following a newly created Tracheostomy:

Apply Suction for only 5- 10 seconds.

The nurse should report BP changes that are greater than a to mmHg difference from the client’s baseline BP.15 to 20 mmHg.

What should be including in PT teaching regarding Organ Donation (2)?Does not affect or delay funeral time or impact funeral/burial expenses.Does not damage or violate the child’s body in a way that would prevent an open casket funeral.

3 Findings associated with a Hemolytic Transfusion Reaction:

Tachycardia Low Back Pain Hypotension

2 Findings associated with Macular Degeneration:

Decreased/Loss of Central Vision Yellow Spots under the Retina

• Findings that places clients at risk for developing a pressure injury include:

Diarrhea & Exposure to Stool.Weight Loss.

• Manifestations of Vaso-occlusive Crisis in a client with Sickle Cell Anemia include:

Painful swelling of the hands & feet.Hematuria.Visual Disturbances.

What is a Priority finding that is an EARLY manifestation of Lithium Toxicity?Confusion.

Other than Confusion, what are 3 other indications of Lithium Toxicity?Coarse Hand Tremors.Incoordination.ECG Changes.Sedation. 1 / 2

First action when implementing an emergency preparedness plan:

Notify the incident commander.

3 Complications associated with Obstructive Sleep Apnea include:

Hypertension.Heart Failure.Cardiac Dysrhythmias.

• Expected findings associated with Methylenedioxymethamphetamine (MDMA)

include:

Diaphoresis Tactile Sensitivity Lowered Inhibition Chills Muscle Cramping Teeth Clenching Mild Hallucinogenic Effects

What should a nurse include in PT teaching for a PT newly prescribed Cyclophosphamide?Maintain hydration with liberal fluid intake.

Expected urinalysis report of a client who has Acute Glomerulonephritis:

Proteinuria.

Colostomy care for a PT using a 2-piece pouching system should include (4):

Cleanse the skin at the stoma site using a washcloth & warm water.Thoroughly dry the skin around the stoma using a patting motion before applying the skin barrier to ensure the pouch adheres to the client’s skin.Activate the adhesive in the skin barrier by holding it place over the stoma for 30 seconds.Cut the skin barrier opening no more than 0.3 cm (0.13 in) larger than the stoma.

Client’s that are prone to Uric Acid Calculi should AVOID eating foods containing

Purine such as (3):

Organ Meats (Liver).Chicken.Red Wines.

Isolation precautions for a Newborn who has Herpes Simplex Virus (HSV):

Contact Precautions.

Nursing Actions when performing a Gastric Lavage for client who has GI Bleeding

& an NG tube in place (4):

Ensure to use lavage solution that is at room temperature.Use 0.9% sodium chloride, sterile water, or tap water for irrigation of the NG tube.

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