HESI EXIT EXAM PN 2019 TEST BANK 1. a male client admitted the morning of his scheduled surgery tells the PN that he drank water last night. What intervention will the PN implement first? Determine the amount of water and exact time it was taken 2. A client receives ondansetron prior to chemotherapy treatment.How should the PN evaluate this medication? Monitor the client for nausea or vomiting following the treatment 3. The PN is caring for an older adult client who is confused and spends...factor contributes to an increased risk for impaired skin integrity for this client? Has increasing episodes of urinary incontinence 4. The pn determines that a client with cirrhosis is experiencing peripheral....take? Protect the clients feet from injury 5. A client is admitted to the postoperative surgical unit after a left lobectomy with two chest tubes......observes the water-sealed chambers, set and prescribed suction of 20cm water...what action should the PN implement? Maintain system integrity and to promote lung reexpansion 6. photo of chest and locating apical HR just below the left nipple 7. At the end of a 12-hour shift the PN observes the urine in a clients drainage..what action should the PN take next? note the most recent white blood count 8. Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his pain...what action should the PN implement first? implement complementary pain relief methods 9. A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in....with one or two word responses. the morning the PN observes that he...Which intervention is most important for the PN to implement? Measure appropriate vital signs 10.The PN is assisting a female client to obtain a voided specimen for uri...meatus. Which intervention is performed next? initiate the urine stream? 11.An 8-year old is placed in 90-90 traction for a fractured femur that resulted from...further action by the PN?weights are touching the foot of the bed 12.The PN is reviewing diet instructions with a female client who has hyper...she has increased her intakes of protein and calories. What action should the PN take? Encourage the client to continue the dietary changes she has made 13.The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis and is preparing for discharge from the hospital. What... -why the fluid measurements need to be recoded 14.-which food types are included when measuring fluid take 15.-what container to use for the most accurate measurement 16.... request return visit for examination after her period when hormones are lowest 17.A mother brings her 5-year old child to the clinic for school physical examinations. Which assessment... PN that intergenerational violence may be occurring in the home? -The 6-year old son hits his younger sister during the interview 18.-the 10-year old daughter has circular burns on her trunk and legs 19.-the 3-year old has multiple bruises on the chest and both legs 20.A client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 mL per hour is...1200 the PN notes that there are 750 ml of solution remaining.At what time should the nurse expect to discontinue the intravenous therapy? 1700 21.the PN is caring for a client who had a total laryngectomy, left radical neck dissection... client is receiving nasogastric tube feedings via an internal pump. today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding? gastric residual volumes 22.A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take? Ensure that all the areolar tissue of the nipple is in the infants mouth. 23.Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? deltoid 24.Before inserting medication into a clients vagina, what instructions should the pn... urinate until bladder is empty 25.An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which information is best for the PN to provide? A history of untreated gonnorhea can lead to PID 26.A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort? Wear a supportive bra at all times 27.A young adult male tells the PN he has declared to change his hours at work so that he can...his community. Which stage of Maslow's development is this young adult attempting to achieve? Self-actualiztion 28.A female client arrives to the clinic for an annal physical examination. when reviewing...the PN that she takes herbs for high blood pressure instead of the prescribed..important for the PN to reinforce with the client? Explain risks associated with using herbs instead of the prescribed antihypertensives. 29.A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client "this type..hospital" what intervention should the PN implement ? Act as the clients advocate when discussing the issue with the HCP 30.The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to include in the nursing care plan? watch the client for abnormal bleeding 31.... "it is better to obtain children acetaminophen to prevent possible side effects from the aspirin " 32.A client is transferred to the surgical unit from the intensive care unit after evacuation of bilateral..primary observation should the PN monitor? neuro-vital signs related to bleeding and intracranial pressure 33.The PN is working the day shift in a long term facility and is preparing..delegate to the UAP to perform during the change of.. total the clients PO intake, fill the water pitchers, empty urinals and catheter bags. 34.While taking the vital signs of a older male client who takes psychotropic medication...uncontrollable hand movements ad is excessively blinking his eyes, which information.... screening for tardive dyskinesia 35.A female client tells the PN that her hemorrhoids are inflamed and hurt..the PN to implement to complete a focused assessment? position client in left lateral position to inspect perianal area for fissures or sacs 36.the PN is implementing the plan of care for a client who admits having...indicates the highest risk for the client acting on these suicidal thoughts? Begins to show signs of improvement 37.The PN observes that a male clients urinary catheter drainage tubing is...the attached to the bed frame. What action should the PN implement? observe the appearance of the urine in the drainage tubing