HESI RN EXIT EXAM- REVIEW

HESI RN EXIT EXAM- REVIEW

TEST BANK 2023

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HESI EXIT COMPREHENSIVE PROCTORED EXAM

• Which information is most concerning to the nurse when caring for an older client with

bilateral cataracts?

• States having difficulty with color perception
• Presents with opacity of the lens upon assessment
• Complains of seeing a cobweb-type structure in the visual field
• Reports the need to use a magnifying glass to see small print

Rationale:

Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment. Distorted color perception, opacity of the lens, and gradual vision loss are expected signs and symptoms of cataracts but do not need immediate attention.

• When caring for a client hospitalized with Guillain-Barré syndrome, which information

is most important for the nurse to report to the primary health care provider?

• Decrease in cognitive status of the client

Rationale:

A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist the client with mechanical ventilation. A primary health care provider will need to be contacted immediately. Options A, C, and D are findings associated with Guillain-Barré syndrome that should also be reported but are not as critical as the client's hypoxic status.

• A client is admitted with a diagnosis of leukemia. This condition is manifested by

which of the following?

• Hyperplasia of the gums, elevated white blood count, weakness

Rationale:

Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia.Options A, B, and D state incorrect information for symptoms of leukemia.

• The nurse enters the examination room of a client who has been told by her health care

provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client? 2 / 4

• "Tell me about what you are feeling right now."

Rationale:

The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings. Giving false reassurance or personal suggestions are not therapeutic communication for the client.

• A nurse working in the emergency department admits a client with full thickness burns

to 50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse take first?

• Prepare to assist with maintaining the airway.

Rationale:

High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with lung injury. Airway management is the first priority of care. Options A, C, and D are all appropriate interventions in managing the client with a burn but are not as critical as establishing an airway.

• The nurse walks into the room and observes the client experiencing a tonic- clonic

seizure. Which intervention should the nurse implement first?

• Turn the client on the side to aid ventilation.

Rationale:

Maintaining the airway during a seizure is the priority for safety. Options A, B, and C are contraindicated during a seizure and may cause further injury to the client.

• Which intervention should be included in the plan of care for a client admitted to the

hospital with ulcerative colitis?

• Provide a low-residue diet.

Rationale:

A low-residue diet will help decrease symptoms of diarrhea, which are clinical manifestations of ulcerative colitis.

• A nurse implements an education program to reduce hospital readmissions for clients

with heart failure. Which statement by the client indicates that teaching has been effective?

• "I will not take my digoxin if my heart rate is higher than 100 beats/min."
• "I should weigh myself once a week and report any increases."
• "It is important to increase my fluid intake whenever possible."
• "I should report an increase of swelling in my feet or ankles."

Rationale:

An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider. Digitalis should be held when the heart rate is lower than 60 beats/min. The client with heart failure should weigh himself or herself daily and report a gain of

• to 3 lb. An increase in fluid can worsen heart failure. 3 / 4

• After assessing a 26-year-old client with type 1 diabetes mellitus, which data may

indicate that the client is experiencing chronic complications of diabetes?

• Blood pressure, 159/98 mm Hg

Rationale:

A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or stroke.

• When caring for a client with a tracheostomy, which intervention should the nurse

delegate to the unlicensed assistive personnel (UAP)?

• Take the vital signs and obtain an O2 saturation level.

Rationale:

The nurse may delegate obtaining vital signs and O2 saturation; however, the nurse is responsible for following up on any reported data.

• The charge nurse is making assignments for the upcoming shift. Which client is most

appropriate to assign to the practical nurse (PN)?

• A client with nausea who needs a nasogastric tube inserted
• A client in hypertensive crisis who needs titration of IV nitroglycerin
• A newly admitted client who needs to have a plan of care established
• A client who is ready for discharge who needs discharge teaching

Rationale:

The client mentioned in option A has a need for a skill that is within the scope of practice for the PN. Titration of an IV drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not delegated.

• A nurse performs an initial admission assessment of a 56-year-old client. Which

factor(s) would indicate that the client is at risk for metabolic syndrome? (Select all that apply.)

• Abdominal obesity
• Sedentary lifestyle
• Hispanic or Asian ethnicity
• Increased triglycerides

Rationale:

Metabolic syndrome is a name for a group of risk factors that increase the risk for coronary artery disease, type 2 diabetes, and stroke (A, B, D, and E).

• Which clinical manifestation in the client with hyperthyroidism is most The apical

heart rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac disorders. Options A, B, and D are all expected findings that should also be reported but are not as critical.

• Apical heart rate of 130 beats/min

Rationale:

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