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Hesi 2021 exit rn latest version

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1. Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 102 F axillary, pulse of 180... beats/minute, and a blood pressure of 90/60 mmHg. Which is the priority intervention to include in this client’s plan of care? A. Keep the suture line clean and dry. B. Check neuro vital signs every 4 hours. C. Maintain intravenous access. D. Measure hourly urine output. ANS: C 2. A client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone (TSH) and low T3 and T4 levels. After the client is admitted to the telemetry unit, which interventions is most important for the nurse to implement? A. Note the client’s most recent hemoglobin level. B. Administer prescribed dose of levothyroxine. C. Offer additional blankets and a warm drink. D. Assess for presence of non-pitting edema. HESI RN ANS: B 3. The nurse observes an unlicensed assistive personnel (UAP) begin to remove exam gloves after emptying a bed pan containing feces. The UAP slides two fingers inside one of the gloves and begins to roll the glove off. Which actions should the nurse implement? [Show More]

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