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 glu...
company law (Catholic University of Eastern Africa)
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NIGHTINGALE COLLEGE HESI EXIT EXAM | ACCURATE
REAL EXAM QUESTIONS WITH DETAILED ANSWERS |
EXPERT VERIFIED FOR GUARANTEED PASS | ACTUAL
EXAM | GRADED A | LATEST UPDATE | 2023/2024
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The nurse notices the older boy becomes withdrawn when asked about what happened.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
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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
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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 reaction
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