HESI with Rationale Exam 2022 with complete solution
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Hesi
HESI with Rationale Exam 2022 with complete solution
The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of the medication?
A. Excessive lochia.
B. Saturation of more than...
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HESI with Rationale Exam 2022 with complete solution
The healthcare provider prescribes methylergonovine maleate for a postpartum
client with uterine atony. What findings should indicate to the nurse to withhold
the next dose of the medication?
A. Excessive lochia.
B. Saturation of more than one pad per hour.
C. Hypertension.
D. Difficulty locating the uterine fundus.
Answer
C. Hypertension.
Rationale
Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can exaggerate
primary hypertension. The nurse should withhold the medication if the client's blood
pressure is elevated (C) and notify the healthcare provider. (A, B, and D) are signs of
uterine atony and are indications for the use of the medication.
The nurse has completed the diet teaching of a male client who is being
discharged following treatment of a leg wound. A high protein diet is encouraged
to promote wound healing. Which lunch choice by the client indicates that the
teaching was effective?
A. A peanut butter sandwich with soda and cookies.
B. A tunafish sandwich with chips and ice cream.
C. A salad with three kinds of lettuce and fruit.
D. Vegetable soup, crackers, and milk.
Answer
B. A tunafish sandwich with chips and ice cream.
Rationale
(B) contains the highest amount of protein. Four ounces of tuna contains 11 g of protein,
and ice cream 5 g of protein per cup. Chips are a fat with virtually no protein value. (A)
contains 4 grams of protein per tablespoon. (C) contains only 1 gram of protein per 1
cup serving. (D) may have beef flavoring but it consist mostly of vegetables and would
therefore be low in protein.
The nurse discontinues a continuous IV heparin infusion for a male client on
strict bed rest, and is now preparing to administer the client's first dose of in
enoxaparin (Lovenox). Prior to giving this subcutaneous injection, which
assessment finding requires additional intervention by the nurse?
A. Current lab report indicates an aPTT at 1.5 times the client's control.
B. Several bruised areas are noted on the client's upper extremities bilaterally.
C. The client states that his right calf is aching, and wants pain medication.
D. The spouse is assisting the client who is shaving with an electric razor.
,Answer
C. The client states that his right calf is aching, and wants pain medication.
Rationale
A calf ache severe enough for the client to request pain medication (C) should be
reported to the healthcare provider immediately so that an adjustment in the
anticoagulation therapy can be made. Calf pain may be a sign of deep vein thrombosis
indicative of ineffective anticoagulant heparin therapy. (A and B) are expected findings.
Shaving with an electric razor is recommended to reduce the possibility of bleeding (D)
and does not require intervention.
While the nurse is providing morning care for a client with chronic obstructive
pulmonary disease (COPD), the client becomes very dyspneic and starts to panic.
What action should the nurse implement first?
A. Instruct the client to perform diaphragmatic breathing.
B. Use a calm voice to tell the client to breathe slowly.
C. Administer two puffs of a metered-dose inhaler.
D. Assist the client to an upright position.
Answer
D. Assist the client to an upright position.
Rationale
The nurse should first assist the client to an upright position (D), which allows the lungs
to expand fully. After this, the nurse can implement (A, B, and C) as needed.
A female client's estranged husband arrives at the hospital and demands that his
wife have no other visitors. The client becomes angry and insists that the
estranged husband be barred from visiting her. Which intervention should the
nurse implement?
A. Obtain a prescription to allow client to dictate who can visit.
B. Request a multidisciplinary care conference to discuss husband's demands.
C. Have the hospital's medical-legal department meet with the client.
D. Encourage the client to speak with husband regarding his disruptive behavior.
Answer
B. Request a multidisciplinary care conference to discuss husband's demands.
Rationale
A multi-disciplinary care conference involves the healthcare team to evaluate difficult
situations that conflict with client safety and autonomy. During this conference, the
client's wishes regarding her health care decisions can be clarified to all team members.
All other options are not indicated.
The nurse working in a critical care unit is assigned the care of two clients, one
with pneumonia who is being mechanically ventilated and the other who had a
thoracotomy yesterday and is complaining of incisional pain. What should the
nurse to first?
,A. Assess the level of consciousness and vital signs for both clients.
B. Complete a head to toe assessment of the client with pneumonia.
C. Change the surgical dressing to observe the appearance of the incision.
D. Review the plan of care and the medications that are due for both clients.
Answer
A. Assess the level of consciousness and vital signs for both clients.
Rationale
Assessing the level of consciousness and vital signs for both clients (A) provides a
quick measurement of priority need. Before a complete assessment (B) is done on one
client, the nurse should at least do a quick assessment of the other client. Changing the
dressing and observing the incision (C) may be indicated, but only after both clients are
quickly assessed. Reviewing the plan of care and medications due for administration
(D) should wait until the nurse has evaluated both clients for any urgent clinical needs.
A woman at 24 weeks gestation who has fever, bodyaches, and has been
coughing for the last 5 days is sent to the hospital with admission prescriptions
for H1N1 influenza. Which prescription has the highest priority?
A. Obtain specimens for cultures.
B. Vital signs q4 hours.
C. Assign private room.
D. Ringers lactate IV 125 mL/8 hours.
Answer
C. Assign private room.
Rationale
Novel H1N1 ("swine flu virus"), a new subtype of influenza A virus, is exhibited by fever,
cough, sore throat, runny nose, body aches, headache, chills, fatigue, diarrhea, and
vomiting. According to the Center for Disease Control, it is best to place a client
requiring Contact or Droplet Precautions in a single client room, so to protect others, the
client who is exhibiting signs of Novel H1N1 influenza should be assigned to a private
room (C). (A, B, and D) do not have the right the priority of (C).
A client who received partial thickness (second degree) burns over the anterior
surfaces of both arms, legs, and chest in a burning vehicle collision receives a
prescription for daily dressing changes and therapeutic baths. The nurse
determines that a hoist is required to move the immobile client from a stretcher
into the therapeutic bath. Which intervention should the nurse implement first?
A. Obtain the hoist from the supply room.
B. Explain the procedure to the client.
C. Medicate the client with an analgesic.
D. Remove all bandages prior to moving the client.
Answer
B. Explain the procedure to the client.
Rationale
, Before implementing any new procedure, an explanation of the procedure should be
provided (B). Bringing large pieces of equipment into the client's room (A), such as a
mechanical lift, may alarm the client if the procedure has not been explained. The client
should be medicated (C), but first explaining what is involved in the procedure helps
prepare the client for subsequent actions. Dressing bandages provide protection for the
wounds and help eliminate exposure to air, which can cause pain, so removal should be
done immediately prior to submersion in the bath (D).
A client develops urticaria on the trunk and neck shortly after a secondary
infusion of piperacillin is initiated. In what order should the nurse implement
these interventions? (Arrange the actions in order of priority, with the highest
priority first and least priority last or at the bottom.)
A. Stop the infusion.
B. Assess vital signs.
C. Contact the healthcare provider.
D. Initiate adverse event report.
E. Document reaction to the drug.
Answer
1. Stop the infusion.
2. Assess vital signs.
3. Contact the healthcare provider.
4. Document reaction to the drug.
5. Initiate adverse event report.
Rationale
The client is exhibiting a drug reaction and quick action is required. When a drug
reaction is suspected, first the infusion should be stopped. Then vital signs and airway
compromise should be assessed and the findings reported to the healthcare provider.
Documentation of the occurrence, including a description of the rash and details of the
reaction should be completed after the healthcare provider is notified. Finally, and
adverse drug reaction or adverse event report should be completed.
The nurse is conducting intake interviews of children at a city clinic. Which child
is most susceptible to contracting lead poisoning?
A. An adolescent who works part time in a paint factory.
B. A 10-year-old who is an insulin-dependent diabetic (Type 1).
C. An 8-year-old who lives in a housing project.
D. A 2-year-old who plays on aging outdoor playground equipment.
Answer
D. A 2-year-old who plays on aging outdoor playground equipment.
Rationale
Children who ingest dust and soil and paint from playground equipment usually practice
pica—the habitual, purposeful, and compulsive ingestion of non-food products,
characteristic of toddlers (D). Lead enters the system by ingestion or inhalation, usually
from paint, gasoline, dust and soil, food, and water. Though (A) may present a hazard,
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