Exam (elaborations)
ALL HESI EXIT QUESTIONS AND ANSWERS TEST BANK (2023/2024): A+ RATED STUDY GUIDE
- Course
- HESI EXIT
- Institution
- Yale University
ALL HESI EXIT QUESTIONS AND ANSWERS TEST BANK (2023/2024): A+ RATED STUDY GUIDE
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ALL HESI EXIT QUESTIONS AND ANSWERS TEST BANK (2023/2024): A+RATED STUDY GUIDE
HESI EXIT STUDY RESOURCE / ATI EXAMS
1. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at
bedtime. What action should the nurse take?
Administer the medication as prescribed with a glass of water
2. Which client should the nurse assess frequently because of the risk for overflow
incontinence? A client
● Who is confused and frequently forgets to go to the bathroom
3. While monitoring a client during a seizure, which interventions should the nurse
implement? (Select all that apply)
● Move obstacle away from client
● Monitor physical movements
● Observe for a patent airway
● Record the duration of the seizure
4. A male client with a long history of alcoholism is admitted because of mild confusion
and fine motor tremors. He reports that he quit drinking alcohol and stoppedsmoking
cigarettes one month ago after his brother died of lung cancer. Which intervention is
most important for the nurses to include in the client’s plan of care?
● Determine client’s level current blood alcohol level.
● Observe for changes in level of consciousness.
● Involve the client’s family in healthcare decisions.
● Provide grief counseling for client and his family.
● Rationale: Based on the client’s history of drinking, he may be exhibiting sing of
hepatic involvement and encephalopathy. Changes in the client’s level of
consciousness should be monitored to determine if he able to maintain
consciousness, so neurological assessment has the highest priority.
5. An older adult female admitted to the intensive care unit (ICU) with a possible stroke is
intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratoryrate of
12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH
7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client’s ABG
finding, which action is required?
● Report the results to the healthcare provider.
● Increase ventilator rate.
● Administer a dose of sodium carbonate.
● Decrease the flow rate of oxygen.
, ● Rationale: This client is experience respiratory acidosis. Increasing the ventilator
rate depletes CO2 a, which returns the PH toward normal. Report findings is
important but only after increasing ventilator rate.
6. The mother of the 12- month-old with cystic fibrosis reports that her child is
experiencing increasing congestion despite the use of chest physical therapy (CPT) twice
a day, and has also experiences a loss of appetite. What instruction should the nurse
provide?
● Perform CPT after meals to increase appetite and improve food intake.
● CPT should be performed more frequently, but at least an hour before
meals.
● Stop using CPT during the daytime until the child has regained an appetite.
● Perform CPT only in the morning, but increase frequency when appetite
improves.
● Rationale: CPY with inhalation therapy should be performed several times a day
to loosen the secretions and move them from the peripheral airway into the central
airways where they can be expectorated. CPT should be done at least one hour
before meals or two hours after meals.
7. ##The nurse is evaluating the diet teaching of a client with hypertension. Whatdinner
selection indicates that the client understands the dietary recommendation for
hypertension?
● Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie
8. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic
episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units
subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are
prescribed. What action should the nurse include in this client’s plan of care?
● Fingerstick glucose assessment q6h with meals
● Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose
● Review with the client proper foot care and prevention of injury
● Do not contaminate the insulin aspart so that it is available for iv use
● Coordinate carbohydrate controlled meals at consistent times and intervals
● Teach subcutaneous injection technique, site rotation and insulin
management
9. Which problem reported by a client taking lovastatin requires the most immediatefallow
up by the nurse?
, ● Diarrhea and flatulence
● Abdominal cramps
● Muscle pain
● Altered taste
● Rationale: statins can cause rhabdomyolysis, a potentially fatal disease of skeletal
muscle characterized by myoglobinuria and manifested with muscle pain, so this
symptom should immediately be reported to the HCP.
10. While assessing a client’s chest tube (CT), the nurse discovers bubbling in the water
seal chamber of the chest tube collection device. The client’s vital signs are: blood
pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32
breaths/minutes, oxygen saturation 88%. Which interventions should the nurse
implement?
● Provide supplemental oxygen
● Auscultate bilateral lung fields
● Administer a nebulizer treatment
● Reinforce occlusive CT dressing
● Give PRN dose of pain medication
● Rationale: the air bubbles indicate an air leak from the lungs, the chest tube site,
or the chest tube collection system. Providing oxygen improves the oxygen
saturation until the leak has been resolved. Auscultating the lung fields helps to
identify absent or decrease lung sound due to collapsing lung.
11. Before leaving the room of a confused client, the nurse notes that a half bow knotwas
used to attach the client's wrist restraints to the movable portion of the client's bed
frame. What action should the nurse take before leaving the room?
● Ensure that the knot can be quickly released.
● Tie the knot with a double turn or square knot.
● Move the ties so the restraints are secured to the side rails.
● Ensure that the restraints are snug against the client's wrist.
12. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media.
An antipyrine and benzocaine-otic also prescribed for pain and inflammation.What
instruction should the nurse emphasize concerning the installation of the
antipyrine/benzocaine otic solution?
● Place the dropper on the upper outer ear canal and instill the medication slowly.
, ● Warm the medication in the microwave for 10 seconds before instilling.
● Keep the medication refrigerated between administrations.
● Have the child lie with the ear up for one to two minute after installation.
13. An older adult male is admitted with complications related to chronic obstructive
pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and
his weakness has increased over the past month. The nurse notes that he has dependent
edema in both lower legs. Based on these assessment findings, which dietary instruction
should the nurse provide?
● Limit the intake of high calorie foods.
● Eat meals at the same time daily.
● Maintain a low protein diet.
● Restrict daily fluid intake.
● Rationale: the client is exhibiting signs of cor pulmonale, a complication of
COPD that causes the right side of the heart to fail. Restricting fluid intake to
1000 to 2000 ml/day, eating a high-calorie diet at small frequent meals with foods
that are high in protein and low in sodium can help relive the edema and decrease
workload on the right-side of the heart.
14. The nurse inserts an indwelling urinary catheter as seen in the video what actionshould
the nurse take next?
● Remove the catheter and insert into urethral opening
● Observe for urine flow and then inflate the balloon.
● Insert the catheter further and observe for discomfort.
● Leave the catheter in place and obtain a sterile catheter.
● Rationale: the catheter is in the vaginal opening.
15. A client with coronary artery disease who is experiencing syncopal episodes is
admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy.
Which intervention should the nurse delegate to the unlicensed assistive personnel
(UAP)?
● Prepare the skin for procedure.
● Identify client's pulse points
● Witness consent for procedure
● Check telemetry monitoring
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