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HESI EXIT Stack 2
| Question | Answer |
|---|---|
| A client at 12-weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement? | Initiate prescribed intravenous fluids |
| A pediatric client is taking the beta-adrenergic blocking agent propranolol. in developing a teaching plan, the nurse should teach the parents to report which sign of overdose? | Bradycardia |
| Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain? | Upper body muscle strength |
| A 3yo boy was successfully trained prior to his admission to the hospital for injuries sustained from a fall. his parents are very concerned that he has regressed in his toileting behaviors. which info should the nurse provide to the parents? | Children usually resume their toileting routine behaviors when they leave the hospital |
| The nurse is managing the care of a client with Cushing's Syndrome. Which interventions should the nurse delegate to the UAP? (SATA) | - Report any client complaint of pain or discomfort - Weigh the client and report any weight gain - Note and report the client's food and liquid intake during meal and snack |
| A young adult visits the clinic reporting symptoms associated with gastritis. Which information int he client's history is most important for the nurse to address in the teaching? | Consume 10 or more drinks of alcohol every weekend |
| After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication? | Ask the client about gastrointestinal pain |
| When assessing a recently delivered multigravida client, the nurse found that her vaginal bleeding is more than expected. Which factor is this history is related to this finding? | She is gravida 6 para 5 |
| When assessing the IV site that is used for replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional finding warrants immediate intervention by the nurse? | Red streak tracking the vein |
| An older adult male abdominal pain is admitted to the hospital from a long-term facility. his last bowel movement was 7 days ago, his abdomen is distended, and he vomited 150 mL of dark brown emesis. In what order should the nurse implement these interven | 1. Elevate the head of the bed 2. Complete focused assessment 3. Offer PRN pain medication 4. Send emesis sample to the lab |
| When taking a health history which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency? | History of intermittent claudication |
| The nurse is providing d/c teaching to the parents of a 13 month old who underwent repair for an atrial septal defect. The HCP prescribed aspirin and an ABX for the first 6 months post-op to prevent infective endocarditis. What info is most important for | Brush the child's teeth every day and ensure the child receive regular dental follow up |
| An UAP is assigned to ambulate a client w/ influenza who has droplet precautions implemented. The UAP requests a change in assignment, stating the reason of having not been fitted for a N95. Which action should the nurse take? | Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client |
| The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? | Clients who developed disease complications promptly received rehab |
| The several nursing problems for client who is immobile and who has been experiencing fecal incontinence and diarrhea for several days. The spouse is the primary caregiver planning care, which problem has the highest priority? | Fluid volume deficit |
| The nurse is feeding an older adult who was admitted w/ aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? | Request thick nectar liquid for the client |
| An adult client is admitted to the ED after failing from a ladder. While waiting to have a CT seam, the client requests something something for a severe headahce. When the nurse offers a prescribed dose of acetaminophen the client ask for something strong | Explain the reason using only non narcotics |
| The nurse is caring for a client who has COPD and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring a client with COPD? | Administering narcotics for pain relief |
| The nurse is providing care for a client w/ schizophrenia who receives haloperidol decanoate 75 mg IM q4weeks. The client begins developing puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement? | Complete Abnormal Involuntary Movement Scale (AIMS) |
| Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect? | Disrupted surfactant production |
| A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the HCP? | Somnambulism |
| The nurse instructs a client is the use of an incentive spirometer. The client performs a return demonstration. Which action should the nurse take in response to the return demonstration? | Remind the client to cough using the spirometer |
| A client tells the nurse about working out w/ a personal trainer and swimming 3x a week in an effort to lose weight and sleep better. The client states that it still is taking hours to fall asleep at night. Which action should the nurse implement? | Ask the client for a description of the exercise schedule that being followed |
| In developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics? (SATA) | - Use common words w/ few syllables - Uses pictures to help illustrate complex ideas - Contains a list w/ definitions of unfamiliar words |
| The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding? | Offer cold pack when pain occurs |
| The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness treatment? (SATA) | - Functional ability - Skin integrity - Pain scale |
| When providing client care, the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When ga | Relevance to the situation |
| A client diagnosed w/ calcium kidney stones has a history of gout. a new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the HCP attention? | Allopurinol |
| A client w/ urge incontinence was treated with onabutuilinumtoxinA injections and is now experiencing urinary retention. Which action should the nurse include in the client's plan of care? | Remind the client to practice pelvic floor (Kegel) exercises regularly |
| After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment should the nurse report to the HCP? (SATA) | - Swollen lymph nodes in the groin - White blood cell count - Core body temperature |
| The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement? | Encourage family member to cook meals outdoors and bring the cooked food inside |
| The nurse is wearing personal protective equipment while caring for a client. When exiting the room, which PPE should be removed first? | Gloves |
| An older male client, retired chef, is hospitalized w/ a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed w/ the way his food is prepared in the hospital. The nurse's response should be based on wha | If the client was compulsive about food when he was younger, the aging process can magnify this |
| A client is receiving enoxaparin 30 mg subQ bid. In assessing for adverse effects of the medication, which serum lab value is most important for the nurse to monitor? | Platelet Count |
| The nurse is caring for a 24 month old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two word phrases. Which assessment should the nurse administer? | The Modified Checklist for Autism in M-CHAT |
| A client with hyperthyroidism is admitted to the post-op unit after a subtotal thyroidectomy. Which of the serum lab values requires intervention by the nurse? | Total calcium 5.0 mg/dL |
| Prior to surgery, written consent must be obtained. Which is the nurse's legal responsibility with regard to obtaining written consent? | Determine that the surgical consent form has been signed and is included in the client's record |
| A client in the 3rd trimester reports that she feels some "lumpy places" in her breast and that her nipples sometimes leak a yellowish fluid. She has an appointment with her HCP in 2 weeks. What action should the nurse take? | Explain that this normal secretion can be assessed at the next visit |
| While the nurse is assessing an older client fall risk the client reports living at home alone and never falling. Which action should the nurse take? | Continue to obtain client data needed to complete the fall risk survey |
| The nurse is providing education to a client who experiencing recurrent levels of moderate anxiety to situations and perceived stress. In addition to info about prescribed medication and administration, which instruction should the nurse include in the te | Practice using muscle relaxation techniques |
Created by:
JuliessaR