HESI V1 2020 EXIT EXAM

QUESTIONS

2. A client who is admitted to the care unit with syndrome of inappropriate antidiuretic

hormone (SIADH) has developed osmotic demyelination. Which intervention should the

nurse implement first?

A) Patch one eye.

B) Evaluate swallow.

C) Reorient often.

D) Range of motion.

Answer:

 B. Evaluate swallow.

Syndrome of inappropriate antidiuretic hormone (SIADH), causes excess water

reabsorption. This causes hemodilution and subsequently, hyponatremia. If

uncorrected, hyponatremia results into osmotic demyelination. One of the earliest

symptoms of osmotic demyelination is dysphagia (difficulty in swallowing). Thus the

nurse should evaluate the client's swallow reflex.

3. The nurse is preparing a client who had a below-the-knee (BKA) amputation for

discharge to home. Which recommendations should the nurse provide this client?

(Select all that apply)

A) Wash the stump with soap and water.

B) Avoid range of motion exercise.

C) Apply alcohol to the stump after bathing.

D) Inspect skin for redness.

E) Use a residual limb shrinker.

 Rationale: Several actions are recommended for home care following an

amputation. The skin should be inspected regularly for abnormalities such as

redness, blistering, or abrasions. A residual limb shrinker should be applied over

the stump to protect it and reduce edema. The stump should be washed daily with

a mild soap and carefully rinse and dried. The client should avoid cleansing with

alcohol because it can dry and crack the skin. Range of motion should be done

daily.

4. After 2 days treatment for dehydration, a child continues to vomit and have diarrhea.

Normal saline is infusing and the child’s urine output is 50ml/hour. During morning

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assessment, the nurse determines that the child is lethargic and difficult to arouse.

Which should the nurse implemented?

A) Increase the IV fluid flow rate.

B) Review 24 hour intake and output.

C) Obtain arterial blood gases.

D) Perform a finger stick glucose test.

D. Perform a finger stick glucose test

Due to the vomiting and diarrhea, the child has not digested or absorbed glucose. The

infusion of normal saline also does not contain glucose. Therefore, the child is likely to

deplete their glucose stores and fall into hypoglycemia. The signs of hypoglycemia

include lethargy and loss of consciousness.

Thus, the nurse should perform a finger stick glucose test, to rule out hypoglycemia.

6. A male client with an antisocial personality disorder is admitted to an in patient mental

health unit for multiple substance dependency. When providing a history, the client

justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this

client’s history is most likely to include which finding?

A) Multiple convictions for misdemeanors and Class B felonies

B) Delusions of grandiosity and persecution.

C) Suicidal ideations and multiple attempts.

D) Photos and panic attacks when confronted by authority figures.

7. An older client is admitted for repair of a broken hip. To reduce the risk for infection

postoperative period., which nursing care intervention should the nurse include the

client’s plan of care? (Select all that apply)

A) Administer low molecular weight heparin as prescribed.

B) Teach client to use incentive spirometer every 2 hours while awake.

C) Remove urinary catheter as soon as possible and encourage voiding.

D) Maintain sequential compression devices while in bed.

E) Assess pain level and medicate PRN as prescribed.

9. A client with arthritis has been receiving treatment with naproxen and now reports

ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should

the nurse monitor?

A) Serum Calcium.

B) Erythrocyte sedimentation rate.

C) Osmolality.

D) Hemoglobin.

10. A client with bacterial meningitis is receiving phenytoin. Which assessment finding

indication to the nurse that the client is experiencing a therapeutic response to the

phenytoin?

A) Increased time of ambulation between periods of rest.

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B) Decrease in intracranial pressure and cerebral edema.

C) Absence of seizure activity for the duration of treatment.

D) Normal electroencephalogram after drug administration.

11. A client peptic ulcer disease receives a prescription for intermittent suction via a

SalemSump nasogastric tube (NGT). After inserting the NGT and obtaining coffeeground gastric contents, the nurse clamps the NGT because the client must leave the

unit for diagnostic studies. Upon return to the unit, the client complains of nausea. What

action should the nurse implement first?

A) Administering a prescribed antiemetic agent.

B) Provide oral suction using a Yankauer tip.

C) Connect the NGT to low intermittent suction.

D) Irrigate the NGT with sterile normal saline.

12. The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000

ml to be influenced over 4 hours. The IV administration set delivers 10 gtt/ml. How many

gtt/minute should the nurse regulate the infusion? ( round the nearest whole number.)

13. A family member reports that the client who is bedridden has not been turned or

repositioned all night and is sleeping on a special air mattress with no sheets. What

information should the nurse provide to the family member?

A) Clarify that an aerated support surface does not use sheets that often cause

skin breakdown.

B) Described the night staff’s plan of care to ensure the client’s sleep is not disturbed.

C) Explained that turning is only necessary to reposition the client during waking hours.

D) Suggest that a family member turn the client during the night when someone is there.

15. A client with bleeding esophageal varies receives vasopressin IV. What should the

nurse monitor for during the IV infusion of this medication?

A) Vasodilation of the extremities.

B) ? Chest pain and dysrhythmia.

C) Hypotension and tachycardia.

D) Decreasing GI cramping and nausea.

16. The healthcare provider prescribes potassium chloride 25 mEq in 500ml D5W to

infuse over 6 hours. The available 20ml vial of potassium chloride is labeled, “How

many ml of potassium chloride should the nurse add to the IV fluid? (Round to the

nearest tenth.)

17. A male client reports to the on-call clinic nurse that he took tadalif 10 mg PO two

hours age and his skin now feels flushed. He reports a history of stable angina, but

denies experiencing any current or recent chest pain. What action should the nurse

take?

A) Tell the client to have someone bring him to an emergency department immediately.

B) Advise the client to place one nitroglycerin tablet under his tongue as a precaution.

C) ?Reassure the client that skin flushing is a common side effect of the medication.

D) Instruct the client to increase his intake of oral until the skin flushing is relieved.

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