Exam (elaborations)
2020 HESI EXIT V2
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Exam of 34 pages for the course 2020 HESI EXIT V2 at 2020 HESI EXIT V2 (2020 HESI EXIT V2)
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2020 HESI EXIT V21. The nurse is teaching parents about diet for a 4 month-old infantwith
gastroenteritis
and mild dehydration. In addition to oral rehydration fluids, the dietshould include
A) Formula or breast milk
B) Broth and tea
C) Rice cereal and apple juice
D) Gelatin and ginger ale
The correct answer is A: Formula or breast milk
2. The nurse instructs the client taking dexamethasone (Decadron) totake it with
food
or milk. What is the physiological basis for this instruction?
A) Retards pepsin production
B) Stimulates hydrochloric acid production
C) Slows stomach emptying time
D) Decreases production of hydrochloric acid
The correct answer is B: Stimulates hydrochloric acid production
3. The nurse is planning care for a 3 month-old infant immediately
postoperative
following placement of a ventriculoperitoneal shunt for hydrocephalus.
The nurse needsto
A) Assess for abdominal distention
B) Maintain infant in an upright position
C) Begin formula feedings when infant is alert
D) Pump the shunt to assess for proper function
The correct answer is A: Assess for abdominal distention
4. The mother of a 2 year-old hospitalized child asks the nurse's adviceabout
the
child's screaming every time the mother gets ready to leave the hospitalroom. What
is the
,best response by the nurse?
A) "I think you or your partner needs to stay with the child while in the
hospital."
B) "Oh, that behavior will stop in a few days."
C) "Keep in mind that for the age this is a normal response to being in the
hospital."
D) "You might want to "sneak out" of the room once the child falls asleep."The
correct answer is C: "Keep in mind that for the age this is a normal response to
being in the hospital."
5. When caring for a client receiving warfarin sodium (Coumadin),which
lab test
would the nurse monitor to determine therapeutic reponse to the drug?
A) Bleeding time
,B) Coagulation time
C) Prothrombin time
D) Partial thromboplastin time
The correct answer is C: Prothrombin time
6. The nurse is caring for a 4 year-old 2 hours after tonsillectomy and
adenoidectomy.
Which of the following assessments must be reported immediately?
A) Vomiting of dark emesis
B) Complaints of throat pain
C) Apical heart rate of 110
D) Increased restlessness
The correct answer is D: Increased restlessness
7. The nurse admits a 7 year-old to the emergency room after a leginjury.
The x-rays
show a femur fracture near the epiphysis. The parents ask what will bethe
outcome of
this injury. The appropriate
response by the nurse should be which of these statements?
A) "The injury is expected to heal quickly because of thin periosteum."
B) "In some instances the result is a retarded bone growth."
C) "Bone growth is stimulated in the affected leg."
D) "This type of injury shows more rapid union than that of younger
children."
The correct answer is B: "In some instances the result is a retarded bonegrowth."
8. A client receiving chlorpromazine HCL (Thorazine) is in psychiatrichome
care.
During a home visit the nurse observes the client smacking her lipsalternately
with
grinding her teeth. The nurse
recognizes this assessment finding as what?
A) Dystonia
B) Akathesia
C) Brady dysknesia
D) Tardive dyskinesia
The correct answer is D: Tardive dyskinesia
9. During the check up of a 2 month-old infant at a well baby clinic, themother
expresses concern to the nurse because a flat pink birthmark on thebaby's
forehead and
eyelid has not gone away. What is an appropriate response by the nurse?
A) "Mongolian spots are a normal finding in dark-skinned children."
B) "Port wine stains are often associated with other malformations."
C) "Telangiectatic nevi are normal and will disappear as the baby grows."
D) "The child is too young for consideration of surgical removal of these atthis
time."
, The correct answer is C: Telangiectatic nevi are normal and will disappearas the
baby
Grows
10. A client has returned to the unit following a renal biopsy. Which ofthe
following
nursing interventions is appropriate?
A) Ambulate the client 4 hours after procedure
B) Maintain client on NPO status for 24 hours
C) Monitor vital signs
D) Change dressing every 8 hours
The correct answer is C: Monitor vital signs
11. A client has been admitted with a fractured femur and has beenplaced in
skeletal
traction. Which of the following nursing interventions should receivepriority?
A) Maintaining proper body alignment
B) Frequent neurovascular assessments of the affected leg
C) Inspection of pin sites for evidence of drainage or inflammation
D) Applying an over-bed trapeze to assist the client with movement in bedThe
correct answer is B: Frequent neurovascular assessments of the affected leg
12. The nurse is teaching a client newly diagnosed with asthma how touse the
metereddose
inhaler (MDI). The client asks when they will know the canister is empty.
The best
response is
A) Drop the canister in water to observe floating
B) Estimate how many doses are usually in the canister
C) Count the number of doses as the inhaler is used
D) Shake the canister to detect any fluid movement
The correct answer is A: Drop the canister in water to observe floating
13. While teaching the family of a child who will take phenytoin (Dilantin)
regularly for
seizure control, it is most important for the nurse to teach them aboutwhich of the
following actions?
A) Maintain good oral hygiene and dental care
B) Omit medication if the child is seizure free
C) Administer acetaminophen to promote sleep
D) Serve a diet that is high in iron
The correct answer is A: Maintain good oral hygiene and dental care
14. A 7 month pregnant woman is admitted with complaints of painlessvaginal
bleeding
over several hours. The nurse should prepare the client for an immediate
A) Non stress test
B) Abdominal ultrasound
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