HESI 2021 EXIT RN LATEST VERSION 4
1. SATA. Older male in ER has become increasingly confused in 3 days; nursing action?
- Determine oxygen saturation rate and breath sounds.
- Evaluate polypharmacy for possible drug interactions.
- Obtain urine and sensitivity for possible UTI.
2. Pt. with bipolar disorder reports not taking his Depakote for 6 mo; nurse assessment?
- Affect
3. Female pt. with pyelonephritis is concerned about dialysis; nurse best initial response?
- Explain the relationship between chronic kidney infection, renal failure, and dialysis.
4. Sickle cell c/o pain in fingers; underlying pathophysiology for pain in sickle cell crisis?
- Sickled red blood cells do not flow through small blood vessels leading to vasocclusion
and ischemia.
5. Pt. at clinical reports new onset of pyrosis and dyspepsia; action has highest priority?
- Instruct the client about the side effects of reflux disease.
6. Pt. bathing with inelastic skin turgor, large pendulous breasts, and a soft, flaccid abdomen.
- Teach the client to dry the skin well between skin folds.
7. Which symptom is characteristic of ureteral colic in the client diagnosed with renal calculi?
- Chills, fever, and dysuria.
8. Suspected GuillianBarre syndrome; which comment is significant to diagnosis?
- “About two weeks ago, I missed a day at work because I had a bad cold.
9. Pt. with burns to posterior neck; which intervention to prevent contractures at injury site?
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- Actively turn head from side to side 90 degrees hourly.
10. Pt. having anxiety reaction when crossing over a bay bridge; action to implement?
- Teach client to listen to music or audio books while driving.
11. Assessing normal development of 9monthold; information to obtain?
- Can the child sit alone?
12. Parkinson’s meds; symptom management requires a balance among neurotransmitters?
- Acetylcholine and dopamine.
13. Pt. with SARS returned from China in isolation; which intervention in plan of care?
- Require use of gown, gloves, and N95 mask.
14. DKA pt. on sliding scale regular insulin; intervention important to implement?
- Confer with the healthcare provider about a continuous IV insulin infusion
15. Teacher thinks she is pregnant (neg test at night) but is on tetracycline for acne; instructions?
- Use first voiding of the day for accurate results of pregnancy test.
16. Child with rheumatoid arthritis has a viral infection and fever/ taking aspirin for arthritis.
- Stop taking aspirin and give different NSAID.
17. Pt. admitted with possible head injury and spinal cord injury; priority assessment?
- Respiratory status
18. Caring for pt. with acute MI; observation warrants immediate intervention?
- The telemetry displays ventricular bigenminy.
19. 2 day posttotal laryngectomy transferred to private room is anxious; intervention?
- Answer the client’s call signal in person quickly after he calls.
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20. Child with HF receiving Lasix with potassium of 3.0 mEq/L; important assessment?
- Cardiac rhythm and heart rate.
21. Child coming to ER with hx of flulike symptoms for past week; equipment to assemble?
- Mechanical Ventilator.
22. What script anticipate for pt. with increased ICP secondary to head injury?
- Mannitol (Osmitrol).
23. Pt. is cigarette smoker and alcohol drinker is postcholecystectomy but tremulous, agitated,
febrile, and disoriented; this is likely the finding of what?
- Impending delirium tremors.
24. Pt. paranoia and homicidal ideation in ER saying daughter lives in TV; thought disorder?
- Easily changes the subject.
25. Infant on Captopril for HF; which finding indicates med effectiveness?
- Blood pressure decreased from 125/85 on admission to 106/60 today.
26. Pt. fell at home and is on labetalol and ranitidine; intervention to include in plan of care?
- Frequent monitoring of blood pressure.
27. Pt. with mitral stenosis at 28weeks gestation; what investigate first?
- Persistent cough.
28. Home care of child with cystic fibrosis; parental action shows understanding?
- Gives pancreatic enzymes before every meal and snack.
29. Child admitted with possible nephrotic syndrome; parent statement goes with diagnosis?
- “I couldn’t get my son’s socks and shoes in this morning.”
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30. Pt. scheduled for laminectomy with back pain r/t intervertebral disk; preop teaching about
numbness and tingling in lower extremities occurs due to?
- Manipulation of nerves and muscles during surgery.
1) A nurse is planning care for a child who has scabies and he keeps itching…
ANS: Keep nails trimmed short and have him wear mittens
2) An acute care hospital has a disaster something about an outage and a generator. The UAP
asks the charge nurse what she can do to help…
ANS: Tell clients to stay in their rooms
3) Discharge teaching to a patient with heart failure what parameter is most important for weight
monitoring…
ANS: Weigh themselves at the same time everyday
4) Patient with metabolic syndrome is going to start exercising what is most important to tell
him…
ANS: Monitor BP as exercise increases
6) Patient c/o pain distal to insertion site, what action should the nurse implement?
ANS: Remove
7) A seriously ill patient that has a DNR is transferred to a medical facility in another state that
does not honor that what should the nurse implement?
ANS: Honor clients wishes
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Version | 2021 |
Category | HESI |
Pages | 50 |
Language | English |
Comments | 0 |
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