HESI RN Exit Exam 2022 (Answered) Verified Solution
The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)?
A. Tachycard...
hesi rn exit exam 2022 answered verified solution the nurse is completing the admission assessment of a 3 year old who is admitted with bacterial meningitis and hydrocephalus which assessment findi
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HESI RN Exit Exam 2022 (Answered) Verified
Solution
The nurse is completing the admission assessment of a 3-year old who is
admitted with bacterial meningitis and hydrocephalus. Which assessment finding
is evidence that the child is experiencing increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope
B. Sluggish and unequal pupillary responses
A client with acute pancreatitis is admitted with severe, piercing abdominal pain
and an elevated serum amylase. Which additional information is the client most
likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly.
A. Abdominal pain decreases when lying supine
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from
the hospital. Which information is most important for the nurse to provide the
parents prior to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family
A. Instructions about how much fluid the child should drink daily
To auscultate for a carotid bruit, the nurse places the stethoscope at what
location. (Select the location on the image with a red dot).
I placed the red dot on the base of the neck on the right side
After receiving report on an inpatient acute care unit, which client should the
nurse assess first?
A. The client with an obstruction of the large intestine who is experiencing
abdominal distention
B. The client who had surgery yesterday and is experiencing a paralytic ileus with
absent bowel sounds
C. The client with a small bowel obstruction who has a nasogastric tube that is
draining greenish fluid
D. The client with a bowel obstruction due to a volvulus who is experiencing
abdominal rigidity
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
A teenager presents to the emergency department with palpitations after vaping
at a party. The client is anxious, fearful, and hyperventilating. The nurse
anticipates the client developing which acid base imbalance?
A. Respiratory acidosis
,B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
D. Respiratory alkalosis
A client with dyspnea is being admitted to the medical unit. To best prepare for
the client's arrival, the nurse should ensure that the client's bed is in which
position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers
Fowlers
The nurse is taking the blood pressure measurement of a client with Parkinson's
disease. Which information in the client's admission assessment is relevant to
the nurse's plan for taking the blood pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling
A. Frequent syncope
C. Flat affect
D. Blurred vision
While caring for a client's postoperative dressing, the nurse observes purulent
drainage at the wound. Before reporting this finding to the healthcare provider,
the nurse should review which of the client's laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level
B. Culture for sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following successful
resuscitation from a near-drowning incident. While providing care to the child, the
nurse begins talking with his preadolescent brother who rescued the child from
the swimming pool and initiated resuscitation. The nurse notices the older boy
becomes withdrawn when asked about what happened. Which action should the
nurse take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions
B. Ask the older brother how he felt during the incident
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he
has been soaking in hot baths at night with no relief of his discomfort. Which
action should the nurse take?
A. Encourage the client to use cooler water and apply calamine lotion after
,soaking
B. Obtain a PRN prescription for an analgesic that the client can use for symptom
relief
C. Suggest that the client take brief showers and apply oil-based lotion after
showering
D. Explain that the symptoms are caused by liver damage and cannot be relieved
A. Encourage the client to use cooler water and apply calamine lotion after soaking
An older client with a long history of coronary artery disease (CAD), hypertension
(HTN), and heart failure (HF) arrives in the Emergency Department (ED) in
respiratory distress. The healthcare provider prescribes furosemide IV. Which
therapeutic response to furosemide should the nurse expected in the client with
acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload
B. Reduced preload
Which intervention should the nurse include in the plan of care for a child with
tetanus?
A. Encourage coughing and deep breathing
B. Minimize the amount of stimuli in the room
C. Reposition from side to side every hour
D. Open window shades to provide natural light
B. Minimize the amount of stimuli in the room
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9,
is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most
likely cause of the ketoacidosis?
A. Ate an extra peanut butter sandwich before gym class
B. incorrectly administered too much insulin
C. Had a cold and ear infection for the past two days
D. Skipped eating lunch
C. Had a cold and ear infection for the past two days
A client with a prescription for "do not resuscitate" (DNR) begins to manifest
signs of impending death. After notifying the family of the client's status, what
priority action should the nurse implement?
A. The impending signs of death should be documented
B. The client's status should be conveyed to the chaplain
C. The client's need for pain medication should be determined
D. The nurse manager should be updated on the client's status
C. The client's need for pain medication should be determined
Which self care measure is most important for the nurse to include in the plan of
care of a client recently diagnosed with type 2 diabetes mellitus?
A. Self-injection techniques
B. Blood glucose monitoring
C. Diabetic diet meal planning
D. A realistic exercise plan
, B. Blood glucose monitoring
A client who gave birth 48 hours ago has decided to bottle feed the infant. During
the assessment, the nurse observes that both breasts are swollen, warm, and
tender on palpation. Which instruction should the nurse provide?
A. Apply ice to the breasts for comfort
B. Wear a loose-fitting bra during the day to prevent nipple irritation
C. Run warm water over breasts
D. Express small amounts of milk from the breasts to relieve pressure
A. Apply ice to the breasts for comfort
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. Avoid range of motion exercises
B. Use a residual limb shrinker
C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
E. Wash the stump with soap and water
B. Use a residual limb shrinker
D. Inspect skin for redness
E. Wash the stump with soap and water
A toddler presenting with a history of intermittent skin rashes, hives, abdominal
pain, and vomiting that occurs after ingesting of milk products arrives to the
clinic accompanied by the parents. Which type of testing should the nurse
provide education to the toddler's family about?
A. Serum immunoglobulin E (IgE)
B. Intradermal test
C. Atopy patch test
D. Placebo-controlled food challenge
A. Serum immunoglobulin E (IgE)
A client who is scheduled for a bronchoscopy in the morning is anxious and
asking the nurse numerous questions about the procedure. In preparing the
client for the procedure, which intervention has the highest priority?
A. Allow client to gargle with warm salt water
B. Administer a sedative to alleviate anxiety
C. Instruct client to write down the questions
D. Deny client's request for a midnight snack
C. Instruct client to write down the questions
The nurse assesses a client one hour after starting a transfusion of packed red
blood cells and determines that there are no indications of a transfusion reaction.
What instruction should the nurse provide the unlicensed assistive personnel
(UAP) who is working with the nurse?
A. Notify the nurse when the transfusion has finished, so further client
assessment can be done
B. Continue to measure the client's vital signs every thirty minutes until the
transfusion is complete
C. Monitor the client carefully for the next three hours and report the onset of a
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