HESI RN EXIT EXAM V2

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HESIEXITEXAM V2 1. The nurse knows that which statement by the mother indicates that themother understands safety precautions with her four month-old infant and her 4year-old child? A) "I strap th... e infant car seat on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket toplay with my 4 year old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuckup in the air while the four year old naps on the sofa." D) "I have the 4 year-old hold and help feed the four month-old a bottle inthe kitchen while I make supper." The correct answer is D: "I have the four year-old hold and help feed thefour month-old a bottle in the kitchen 2. Upon completing the admission documents, the nurse learns that the87 year-old client does not have an advance directive. What action should the nurse take? A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary The correct answer is B: Give information about advance directives 3. A nurse administers the influenza vaccine to a client in a clinic. Within15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered The correct answer is B: Administer epinephrine 1:1000 as ordered . 4. Which of these children at the site of a disaster at a child day carecenter would the triage nurse putin the "treat last" category? A) An infant with intermittent bulging anterior fontanel between crying episodes B) A toddler with severe deep abrasions over 98% of the body C) A preschooler with 1 lower leg fracture and the other leg with an upperleg fracture D) A school-age child with singed eyebrows and hair on the arms The correct answeris B: A toddler with severe deep abrasions over 98% ofthe body . 5. When admitting a client to an acute care facility, an identificationbracelet is sent up with the admission form. In the event these do not match, the nurse’sbest action is to A) Change whichever item is incorrect to the correct information B) Use the bracelet and admission form until a replacement is supplied C) Notify the admissions office and wait to apply the bracelet D) Make a corrected identification bracelet for the client The correct answer is C: notify the admissions office and wait to apply thebracelet 6. The nurse is having difficulty reading the health care provider's writtenorder that was written right before the shift change. What action should be taken? A) Leave the order for the oncoming staff to follow-up B) Contact the charge nurse for an interpretation C) Ask the pharmacy for assistance in the interpretation D) Call the providerfor clarification The correct answer is D: Call the provider for clarification 7. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be takenby the nurse is to: A) check the carotid pulse B) deliver 5 abdominal thrusts C) give 2 rescue breaths D) open the client's airway The correct answer is D: open the client''s airway 8. A client has an orderfor 1000 ml of D5W over an 8 hour period. Thenurse discovers that 800 ml has been infused after 4 hours. What is the priority nursingaction? A) Ask the client if there are any breathing problems B) Have the client void as much as possible C) Check the vitalsigns D) Auscultate the lungs The correct answer is D: Auscultate the lungs 9. Following change-of-shift report on an orthopedic unit, which clientshould the nurse see first? A) 16 year-old who had an open reduction of a fractured wrist 10 hoursago B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident C) 72 year-old recovering from surgery after a hip replacement 2 hoursago D) 75 year-old who is in skin traction prior to planned hip pinning surgery.The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2 hours ago 10. A nurse observes a family member administer a rectalsuppository byhaving the client lie on the left side for the administration. The family memberpushed the suppository until the finger went up to the second knuckle. After 10minutes the client was told by the family member to turn to the right side and the client didthis. What is the appropriate comment for the nurse to make? A) Why don’t we now have the client turn back to the left side. B) That was done correctly. Did you have any problems with the insertion? C) Let’s check to see if the suppository is in far enough. D) Did you feel any stool in the intestinal tract? The correct answer is B: That was done correctly. Did you have anyproblems with the insertion? [Show More]

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