1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One
hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the
client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to
reporting the finding to the surgeon. Which action should the nurse implementfirst?
a. Measure and documentthe client’s urinary output.
b. Requestthe client’sreservedunitif packed red blood cells.
c. Prepare the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer’ssolution.
2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to
the intensivecare unit(ICU).the nurse notesthatthe suction control chamberis bubbling atthe
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red
blood ismeasured in the collection chamber. Which intervention shouldthe nurse implement?
a. Add sterile waterto the suction control chamber.
b. Give blood fromthe collection chamber as autotransfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wallsuction to eliminatefluctuation inwaterseal.
3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is
manifesting shortness of breath, bilateral2+pedal edema, and an oxygen saturation on roomair
of 89%. Which action should the nurse take first?
a. Elevate the foot ofthe bed.
b. Restrict the client’s fluid.
c. Begin supplemental oxygen.
d. Prepare the clientforhemodialysis.
4. A clientwith Addison’s crisisis admitted fortreatmentwith adrenal corticalsupplementation.
Based on the client’s admitting diagnosis, which findings require immediateaction by the nurse?
(Select all that apply)
a. Headache and tremors
b. Irregularheartrate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding
isthe best indicatorof hydration thatthe nurse should reportto the healthcare provider?
a. Urine specific gravity is 1.040
b. Systolicblood pressure decreases 10points when standing.
c. The client denies being thirsty.
d. Skin tenting occurs when the client’sforearmis pinched.
6. After an inservice about electronic health record (EHR) security and safeguarding client
information, the nurse observes a colleague going home with printed copies of client
information in a uniformpocket. Which action should the nurse take?
a. File adetailed incidentreportwiththe specifichiring facility.
b. Warn the colleague thattheir actionsare unprofessional.
c. Comment anonymously aboutthe action of a staff discussion board.
d. Communicate the colleague’s actionsto the unit charge nurse.
7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease
implemented in a rural health clinic. Which outcomeindicatethe programis effective?
a. At-risk clientsreceivedan increased numberofroutine health screenings.
b. Clientsreported havingnew confidence inmaking healthy food choices.
c. Clients who incurred diseasecomplications promptly received rehabilitation.
d. Clientrelapserate of 30% in a 5-year community-wideanti-smoking campaign.
8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses
oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is
having increased shortness of breath with respirations at 23 breaths/minute. Which action
should the nurse implementfirst?
a. Determine ifthe clientis experiencing any anxiety.
b. Auscultate the client’sbilateral lung sounds and oxygen saturation.
c. Notify the healthcareprovider aboutthe client’s distress.
d. Assessthe deliverymechanismofthe oxygen tank,tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an
immediateinvestigation by the nurse?
a. “When I get out of bed quickly, I feel a littledizzy.”
b. “The dressing overmy incision feelslikeitistoo tight.”
c. “I’mmost comfortable when the head ofthe bed israised.”
d. “ThisIV infusionmakesme urinate more often than usual.”
10. An older adult male who is in his early 70’s is admitted to the emergency department because of
a COPD exacerbation. This clientis struggling to breathe and the healthcare teamis preparing
for endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the
nurse to stop the procedure and provide the nurse a copy of the client’s living will. Which acti on
should the nurse take?
a. Facilitate a family meeting with the palliative care team.
b. Notify the healthcare providerofthe client’s wishes.
c. Place a certifiedcopy ofthe livingwillin the client’s record.
d. Alertthe nursing staff ofthe client’s don’tresuscitate status.
11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the
client is so obese that the UAP feels unable to safely assist the client in transferring from the bed
to the bedside commode.How should the nurserespond?
a. Determine the client’slevelof mobility and need for assistance.
b. Instructthe UAP that all clients deserveequal care.
c. Advice the clienttomaintainbedrestso thatsafety can be ensured.
d. Assign another UAP to care forthe client.
12. A nurse determines that more than 25% of the students at a middle school are overweight. The
nurse presents the information at the parent-teacher meeting. What action is most important
forthe nurse to include in the meeting?
a. Provide informationon waysto increase activity forthe family.
b. Have several teachers talk about health risks associated with obesity.
c. Distribute a shopping list ofsuggestedhealthy snack items.
d. Determine the parents’degreeof concern abouttheir children’s weight.
Version | LATEST 2022 |
Category | HESI |
Release date | 2022-07-11 |
Included files | |
Authors | Qwivy.com |
Pages | 37 |
Language | English |
Tags | HESI EXIT RN 2022 V3 160 Questions |
Comments | 0 |
High resolution | Yes |
Sales | 0 |
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