HESI RN EXIT EXAM V2/ Latest 2022:2023/ Questions & Answers

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1. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action sho... uld the nurse take before leaving the room? a) Ensure that the restraints are snug against the client's wrists. b) Move the ties so the restraints are secured to the side rails. c) Ensure that the knot can be quickly released. d) Tie the knot with a double turn or square knot. (ANS- c) Ensure that the knot can be quickly released. 2. When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client? a) Doubt b) Observation c) Confrontation d) Reflection (ANS- d) Reflection 3. The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? a) Lip smacking and frequent eye blinking b) Shuffling gait and stooped posture c) Rocks back and forth in the chair d) Muscle spasms of the back and neck (ANS- d) Muscle spasms of the back and neck 4. A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain? a) Presence of bruising, weakness, or fatigue b) Therapeutic exercise included in daily routine. c) Average amount of protein eaten daily d) Existence of gastrointestinal discomfort (ANS- b) Therapeutic exercise included in daily routine. 5. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse? a) Diabetic ketoacidosis and titrated IV insulin infusion b) Emphysema extubated 3 hours ago receiving heated mist c) Subdural hematoma with an intracranial monitoring device d) Acute coronary syndrome treated with vasopressors (ANS- a) Diabetic ketoacidosis and titrated IV insulin infusion 6. A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering? a) Beta blockers b) Bronchodilators c) Corticosteroids d) Beta-adrenergics (ANS- b) Bronchodilators 7. The nurse weighs a 6-month-old infant during a well baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? a) What food does your baby usually eat in a normal day? b) What was the baby's weight at the last well-baby clinic visit? c) The baby is below the normal percentile for weight gain d) Your baby is gaining weight right on schedule (ANS- What food does your baby usually eat in a normal day? 8. The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse? a) Finger stick blood glucose 120 mg/dL post exchange b) Arteriovenous (AV) graft surgical site pulsations. c) Anorexia and poor intake of adequate dietary protein d) Cloudy dialysate output and rebound abdominal pain (ANS- Cloudy dialysate output and rebound abdominal pain 9. A male client with renal cell carcinoma is returned to the unit following a radical nephrectomy. The nurse notes that his vital signs and urine output are within normal range, his bandage is dry, and the drain from the incision site is producing a small amount of serasanguinous drainage. Which intervention should the nurse implement? a) Place a pressure bandage at the drainage site b) Document assessment findings in the electronic medical record c) Monitor urinary catheter output for a decrease below 30 ml/hr d) Notify surgeon of color and amount of wound drainage. (ANS- Notify surgeon of color and amount of wound drainage 10. A client with chronic obstructive lung disease, who is receiving oxygen at 1.5 liters/minute by nasal cannula, is currently short of breath. What action should the nurse take? a) Ask the client to take short, rapid breaths b) Instruct the client in pursed lip breathing c) Increase oxygen to three liters/minute d) Have the client breathe into a paper bag (ANS- Instruct the client in pursed lip breathing 11. The nurse assesses a male client following surgery for a gunshot wound to the abdomen and determines that his dressing is saturated with blood and petechiae are on his extremities. His current blood pressure is 80/40, and his heart rate is 130 beats/minute. Which laboratory finding confirms the presence of disseminated intravascular coagulopathy (DIC)? a) Low prothrombin time b) Elevated fibrinogen c) Positive d-Dimer d) Normal hemoglobin (ANS- Elevated fibrinogen 12. After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse? a) Blood pressure 170/98 b) Joint and muscle aches c) Urine output 300 ml/hr d) Dark, rust-colored urine (ANS- Urine output 300 ml/hr 13. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? a) Evaluate the client's ability to use an incentive spirometer b) Monitor the amount of drainage from the client's incision c) Observe both lower extremities for redness and swelling d) Palpate all peripheral pulse points for volume and strength (ANS- Monitor the amount of drainage from the client's incision [Show More]

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