HESI Comprehensive Exit Exam Test Bank Answered A+ Solution Guide; Spring 2022
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Course
Hesi PN Comprehensive (HESIPN)
Institution
Keiser University
HESI Comprehensive Exit Exam Test Bank Answered A+ Solution Guide; Spring 2022
Question:-A nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing acute mania, which of the following interventions should the nurse include in the plan of care?
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hesi comprehensive exit exam test bank answered a solution guide spring 2022
hesi comprehensive exit exam
hesi comprehensive exit exam test bank answered
hesi comprehensive exit exam test bank 2022
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Hesi PN Comprehensive (HESIPN)
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HESI Comprehensive Exit Exam Test Bank Answered A+ Solution Guide; Spring 2022
Question:-A nurse is contributing to the plan of care for a client who has bipolar disorder and is
experiencing acute mania, which of the following interventions should the nurse include in the plan of
care?
{{ANS}}• Provide the client with high calorie finger foods)
Question:-A nurse is reinforcing with a new mother on facility security measures, which of the following
statements by the mother indicates an understanding of the teaching?
{{ANS}}• I will have an identification band that matches the one my baby wears)
Question:-A nurse is preparing to perform a 12 lead ECG for a client who reports palpitations, which of
the following actions should the nurse take to insure an accurate capture of the client's heart rate and
rhythm? SATA
{{ANS}}• Position the electrodes on the client's chest and extremities • Tell the client to expect
sensations similar to static electricity during the test • Explain to the client that movement can alter the
test results)
Question:-A nurse is completing documentation in the medical record about a client who fell on the floor,
which of the following statements should the nurse include in the documentation?
{{ANS}}• The client stated "I lost my balance and fell when I got out of bed to the bathroom")
Question:-5. A nurse and a family practice office routinely review client's immunization status at their
annual physical examination visit, for which of the following clients should the nurse recommend human
papillaou virus immunization (HPV Virus)?
{{ANS}}• a teenage boy)
Question:-A nurse is caring for a client who is 2 days post-operative following a surgical creation of an
ileostomy and is tolerating oral intake, which of the following actions should the nurse take?
{{ANS}}Empty the ileostomy pouch every 2-3 hours)
Question:-Anurse is assisting for the plan of care for the client who has burns to his lower extremities,
which of the following actions should the nurse include. in the plan?
{{ANS}}Clean the most contaminated wound first)
Question:-A nurse begins to bathe a newly admitted client who reports that she has not had anything to
eat that day, the nurse interrupts the bath and obtains a healthy meal for the client. This action by the
nurse is an example of which of the following?
{{ANS}}Boundary crossing)
Question:-A nurse enters the room of a school aged child and finds him on the floor experiencing a tonic
colonic seizure, which of the following actions should the nurse take?
{{ANS}}Place a pillow under the client's head)
Question:-A nurse is collecting data from a client who has acute cholecystitis, which of the following
findings should the nurse expect?
{{ANS}}Pain in the right upper abdomen)
,Question:-A nurse is reinforcing teaching with the family of the client who is terminally ill about the grief
process, which of the following information should the nurse include in the teaching?
{{ANS}}Anticipatory grieving prolongs the grief process)
Question:-A nurse is providing support to the family of a school aged child who has a new diagnosis of a
terminal illness, which of the following actions should the nurse take?
{{ANS}}Provide the family with time to talk openly)
Question:-A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine, which
of the following adverse effects should the nurse include on the teaching as indication of serotonin serum?
{{ANS}}Diaphoresis)
Question:-A nurse is reinforcing teaching with a client who is at 36 weeks of gestation and is about to
undergo an amniocentesis, which of the following information should the nurse include in the
instructions?
{{ANS}}You will need to have an empty bladder for the test)
Question:-A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has
mild hypertension, which of the following statements by the client indicates an understanding of the
teaching?
{{ANS}}I should decrease my salt intake to 2g per day)
Question:-A nurse is checking for gastric residual volume on the client who is scheduled to receive an
intermittent enteral feeding. The nurse finds that the client has a GRV greater than 250mLs on two
consecutivemeasurements, which of the following actions should the nurse take?
{{ANS}}Hold the feeding and recheck the GRV in one hour)
Question:-A nurse is caring for a client who is one day post-operative following a total hip arthroplasty
and is receiving Heparin subcutaneously, which of the following adverse effects of the medication should
the nurse report to the provider?
{{ANS}}Epistaxis)
Question:-18. A nurse is collecting data during a muscle skeletal examination of a client who has spinal
colon deformity and reports back pain, which of the following images should the nurse identify as an
indication of the client has kyphosis?
{{ANS}}Person with higher lump on back)
Question:-A nurse in a clinic is reviewing the medical record of a toddler and notes that he previously had
a severe allergic reaction to a gelatin, which of the following immunizations should the nurse identify as
unsafe for this client to receive?
{{ANS}}Measles Mumps and Rubella (MMR))
Question:-A nurse is caring for a 3yr old child immediately following a clinic tonic seizure, which of the
following actions should the nurse take?
{{ANS}}Check the child for oral injuries)
Question:-A nurse is delegating client care assignments, which of the following tasks should the nurse
assign to assistant personnel?
{{ANS}}Apply an anti-embolic stocking for a client who is 2 days post-operative)
Question:-A nurse is reviewing the health history of a middle adult client who is receiving chemotherapy
,for leukemia, which of the following immunizations should the nurse recommend that the client receives?
{{ANS}}Inactive Influenza)
Question:-A nurse is reinforcing discharge teaching with a client who has angina and a prescription for
sublingual nitroglycerin tablet, which of the following statement by the client indicates an understanding
of the teaching?
{{ANS}}I should expect pain relief in 1-3 minutes)
Question:-A nurse is monitoring a client for hyperkalemia, which of the following findings should the
nurse report to the provider?
{{ANS}}Irregular heartbeat)
Question:-A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The
client tells the nurse that he always experiences diarrhea when taking antibiotics, which of the following
food choices should the nurse recommend to lessen the occurrence of diarrhea?
{{ANS}}Yogurt)
Question:-A nurse is caring for a client who has advanced colorectal cancer and reports that her daughter
insists on caring for her at home without assistance. The client states that she prefers help for home health
care and hospice, which of the following responses should the nurse make?
{{ANS}}I can be with you while you explain your feelings about your care to your daughter)
Question:-A nurse is collecting data from a client who is 12 hours postoperative following an intestinal
surgery. which of the following findings should the nurse report to the charge nurse prior to client
ambulation.
{{ANS}}oxygen saturation 90%)
Question:-A nurse is reinforcing teaching about home safety precautions with the parent of a 3- month-
old infant which of the following should the nurse include in the teaching
{{ANS}}remove bibs when the infant is going to sleep)
Question:-A nurse is caring for a client who is to undergo a subtotal thyroidectomy which of the
following items should the nurse place at the client's bedside
{{ANS}}tracheostomy kit)
Question:-A nurse is reinforcing teaching with a parent of a child who has ADHD and is taking
methylphenidate which of the following statements by the parents indicated the medication is effective
{{ANS}}our child is able to complete his homework on time)
Question:-A nurse is reinforcing teaching with a client who has primary open angle glaucoma and a new
prescription for timolol eye drops. which of the following statements by the client indicates an
understanding of the teaching
{{ANS}}I I should check my heart rate while taking this medication)
Question:-A home health nurse is caring for a client who has Alzheimer's disease. the client's son is
concerned about his mother becoming frustrated. which of the following interventions should the nurse
include?
{{ANS}}make a schedule for daily tasks)
Question:-A nurse is reinforcing teaching with a client who has coronary artery disease and a new
prescription for warfarin which of the following should the nurse include in the teaching
, {{ANS}}take the medication at the same time everyday)
Question:-A nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has
hyperemesis gravitation, which of the following client statements indicates and understanding of the
nurse's instructions.
{{ANS}}I will wait 1 hour before getting up in the morning before having breakfast)
Question:-A nurse is contributing to the plan of care for a chest tube set to continue a suction to relieve a
pneumothorax which of the following should the nurse include
{{ANS}}ensure that the device is kept below the level of the clients chest)
Question:-A nurse is caring for a client who is terminally ill and is comatose the client has a living will
that has a DNR order. The client's son requests removal of the DNR order which of the following actions
should the nurse take.
{{ANS}}place a hold on the order until review of the ethics committee)
Question:-A nurse is caring for a client who is recently diagnosed with depression the clients partner asks
when he will get better which of the following is the appropriate response by the nurse
{{ANS}}tell me what you know about depression)
Question:-A nurse is reinforcing dietary teaching with a client who has Cushing's syndrome which of the
following statements indicates an understanding of the client
{{ANS}}I will limit my sodium intake)
Question:-39. A nurse is reinforcing teaching with a group of AP about intimate partner violence the
nurse should include that which of the following is a common characteristic of a predictor for intimate
partner violence
{{ANS}}possessiveness)
Question:-A nurse is collecting data from a client who uses a continuous positive airway pressure çpap
machine at night for sleep apnea. the nurse should identify which of the following indicates proper use
{{ANS}}there is one finger width between he straps and the face)
Question:-A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing
lower back pain. which of the following recommendations should the nurse make?
{{ANS}}perform pelvic rocking exercises several times per day)
Question:-A nurse is collecting data from a client who diabetic ketoaçidosis, which of the following
findings should the nurse expect?
{{ANS}}Fruity breath)
Question:-A nurse is reinforcing discharge teaching with the family of an older adult client about safety
precautions when administering a hypotonic enema to the client, which of the following instructions
should the nurse include in the teaching?
{{ANS}}Instruct the client to inhale while inserting the rectal tube)
Question:-A nurse is collecting data from an adolescent client who has experienced sexual abuse, which
of the following statements by the client should the nurse recognize of the use of the defense mechanism
of suppression?
{{ANS}}I drink beer as often as I can, so I don't have to think about all of the times it happened)
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