HESI EXIT RN EXAM V3 2022

Exam For Health Education Systems, Inc (HESI) Exit Registered Nurse Version 3, 2022

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HESI Exit Version 3, 2021/2022 100% Correct Inquiries & Answers

The healthcare provider is inspecting medical orders for newly admitted clients. The main concern for the healthcare provider would be to follow up with the physician if a client with (a) a potassium level of 4.5mEq/L has been prescribed Kayexalate (sodium polystyrene) (b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions (c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen) (d) sensitivity to Penicillin is prescribed Zithromax (azithromycin). The healthcare provider should intervene if the healthcare provider notices a staff member (a) obtaining a client’s consent prior to their operative procedure after receiving Ativan (lorazepam) (b) placing a client on the affected side following surgical repair of a retinal detachment (c) handling a wet cast with the palms of the hands (d) using a broad base of support while transferring a client.

The community health nurse is tending to the following clients. It would be a top priority for the nurse to initiate a multi-disciplinary conference for the client who is (a) 12 years old with Autism starting a new school and recently had a URI (upper respiratory tract infection) (b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent Hemoglobin A1c of 13% (c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and employed as a mail carrier (d) 70 years old, has schizophrenia, lives alone and reports hearing non-threatening voices.

The nurse from the postpartum unit has been temporarily assigned to the medical-surgical unit. It would be most appropriate to assign this nurse to the client who has (a) returned from right total hip replacement surgery 4 hours ago (b) is being observed for increased intracranial pressure 2 10. 11. 12. 13. The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse would be correct to include which of the following examples? (a) Placing a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is false imprisonment (b) Informing a client that a feeding tube will be inserted if the client refuses to eat is an example of battery (c) Informing a client with bipolar disorder who is suicidal that they have a right to refuse to take their medicines is an example of malpractice (d) Placing hands on a client who says “do not touch me” is an example of assault

The nurse from the pediatric unit has been temporarily assigned to the Emergency Department. It would be most appropriate to assign that nurse to the client who reports epigastric pain that “feels like indigestion” and has back pain and a pulsating abdominal mass, is HIV-positive reporting vomiting and diarrhea, or presents with lower abdominal pain and is six weeks pregnant. Four clients recently returned to the unit following invasive diagnostic testing. The nurse should immediately intervene if one of the clients reports blood-tinged sputum following a bronchoscopy, has decreased abdominal girth following paracentesis, reports a headache following a lumbar puncture, or is observed flexing and extending the legs two hours after cardiac catheterization.

The nurse is made aware of the following situations. The nurse should first assess the client who has had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours after the indwelling catheter is removed, has cervical traction and is moving the legs by flexing and extending the feet, has Alzheimer’s disease (stage 1) and was returned to the room after being found wandering in the hallway, or has a history of partial seizures and is sitting in the bed picking on the clothes and smacking the lips.

The nurse in a community health clinic is communicating with the parent of a child with Celiac Disease. Which of the following statements would require follow-up by the nurse for additional teaching? “This weekend we are going to a seafood restaurant” “I can feed my child oatmeal and eggs for breakfast” “My child likes to eat rice and chicken for dinner” “Last night we ate fish with corn for dinner” The charge nurse is observing a Licensed Practical Nurse (LPN) providing care for assigned clients. Follow-up shall be required if the LPN assesses a client’s apical pulse before administering Digoxin (lanoxin), elevates the client’s stump on a pillow eight hours after amputation, dons a clean glove on the dominant hand before tracheal suctioning, or positions a client on the operative side following a pneumonectomy.

The nurse at a health promotion fair has taught a group of parents about car seat and seat belt safety. Which of the following statements, if made by the parent, would indicate an accurate understanding of the information given? “I will place my newborn infant in a rear-facing car seat in the middle of the rear seat” “I will wear a lap seat belt high on my abdomen since I am 8 months pregnant” “I can use a front-facing car seat once my baby weighs 15 pounds” “I can allow my six-year-old to use a seat belt in the front passenger seat”

The nurse is caring for a client being treated for Vancomycin-Resistant Enterococcus (VRE). The nurse should place the client on contact precautions, droplet precautions, protective precautions, or airborne precautions. The nurse is caring for a client with a Vancomycin-Resistant Enterococcus (VRE) wound infection. Which of the following actions would be appropriate for the nurse to take? Wear a particulate respirator mask when providing wound care Instruct visitors to not bring flowers into the client’s room

The nurse should anticipate that the client will initially be prescribed Disease-Modifying Antirheumatic Drugs (DMARDs), Nonselective Anti-Inflammatory Drugs (NSAIDs), Long-term corticosteroids, or Biologic Response Modifiers. The nurse is assessing a 2-month-old infant at a well-baby clinic. The nurse should anticipate the infant should roll from prone to back, don’t have any head lag, smile socially, or don’t have any tonic neck reflex. The nurse is educating a class on infant nutrition. The nurse should instruct parents to introduce fruit juices at 3 months, honey-sweetened water at 6 months, pureed chicken at 7 months, or whole milk at 9 months. The nurse is caring for a 7-year-old who has thrombocytopenia and is on protective precautions. Which of the following would be an appropriate toy for the nurse to provide to the client? Finger paints and paper, a rubber ball and bat, a board game, or a stuffed toy. The nurse on a pediatric unit has been informed that the following clients are being admitted. The nurse should first plan to assess the client who is at 2 years old with a temperature of 100.8°F and a blood pressure of 68/44, 4 years old with a history of asthma and has a peak expiratory flow rate (PERF) of 81%, 5 years old with a fracture of the tibia and is reporting pain rated 7 on a pain scale of 0 (no pain) to 10 (severe pain), or 7 years old with ulcerative colitis and has had 15 blood-tinged stools today. The nurse is providing discharge instructions to the parents of an infant who has a cleft lip. The nurse should instruct the parents to place the infant in a prone position after each feeding, encourage the parents to provide the infant rest periods during feedings or have informed that the child is given the Haemophilus Influenza Type b (HIB) is given yearly to protect against the flu.
The mother of an infant tells the nurse that the baby has not been tolerating feedings recently and she noticed an olive-shaped mass in the baby’s abdomen. The nurse recognizes that this could be an expected finding if the baby has intussusception, Hirschsprung’s disease, umbilical hernia, or pyloric stenosis. The nurse is teaching a group of parents about the expected growth and development of three-year-old children. The nurse should include that a three-year-old should discriminate between fantasy and reality, ride a tricycle independently, have a vocabulary of 7,000 words, or play in a group of two or three with one being the leader. The nurse and the nursing assistant are caring for a group of clients. Which of the following client care actions should the nurse assign to the nursing assistant? Reinforcing the dressing of a client who has a decubitus ulcer, monitoring the vital signs of a client who had a myocardial infarction 12 hours ago and is being transferred from the coronary care unit, administering a prescribed Fleet’s enema to a client who will undergo a colonoscopy in two hours, inserting a client who had an above-the-knee amputation 24 hours ago in a prone position, assisting a client who had a colon resection 36 hours ago to ambulate, showing a client who had a vaginal hysterectomy 36 hours ago how to perform perineal care. The nurse is caring for a client with Acquired Immunodeficiency Syndrome (AIDS) who was started on Zidovudine (AZT). It would be important for the nurse to assess blood ammonia serum, serum potassium, complete blood count (CBC), or serum uric acid. The nurse is performing an abdominal assessment. Indicate the correct sequence the nurse should use to perform this assessment: percussion, palpation, auscultation, inspection. Answer, the nurse has become aware of the following client situations. The nurse should first assess the client who has acquired a unit of packed red blood cells 4 hours ago and is requesting a bedpan, had an abdominal hysterectomy yesterday and is reporting calf pain, has a history of multiple sclerosis and is reporting diplopia, or had a tonsillectomy three hours ago and is reporting a sore throat. The nurse is caring for a client who has been prescribed 1,000 ml of Ringer’s Lactate to infuse over 8 hours. The available intravenous set delivers 10 drops per milliliter. How many drops per minute should the nurse set the intravenous controller to administer? Answer, 21 gtts/min. Volume 1000ml X Drip factor (10gtts/ml) Time in minutes (8 hours x 60 minutes) The primary health care provider has prescribed an oral solution of Potassium Chloride (KCL) 20 mEq PO, QD. The drug available is Potassium Chloride 10 mEq/15ml. How many ml should the nurse administer? Answer, 30 ml. Desired volume (20 mEq) X Quantity (15 ml) The nurse is caring for a client with smooth tissue injury. The client reports using a herbal remedy for three weeks prior to seeking health care but cannot remember what was taken. The nurse should recognize that which of the following herbal remedies may be applied effectively for