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HESI RN EXIT EXAM 2023 TEST BANK /RN HESI EXIT TEST BANK 300 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS$22.99
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Following discharge teaching, a male client Review with the client the need to avoid foods that are rich in milk and cream
with duodenal ulcer tells the nurse the he
will drink plenty of dairy products, such as Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be
milk, to help coat and protect his ulcer. What avoided.
is the best follow-up action by the nurse?
a. Remind the client that it is also important
to switch to decaffeinated coffee and tea.
b. Suggest that the client also plan to eat
frequent small meals to reduce discomfort
c. Review with the client the need to avoid
foods that are rich in milk and cream.
d. Reinforce this teaching by asking the client
to list a dairy food that he might select.
,A male client with hypertension, who Stroke secondary to hemorrhage
received new antihypertensive prescriptions
at his last visit returns to the clinic two weeks Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
later to evaluate his blood pressure (BP). His hypertension.
BP is 158/106 and he admits that he has not
been taking the prescribed medication
because the drugs make him "feel bad". In
explaining the need for hypertension
control, the nurse should stress that an
elevated BP places the client at risk for which
pathophysiological condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular
damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
The nurse observes an unlicensed assistive Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
personnel (UAP) positioning a newly
admitted client who has a seizure disorder. Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest
The client is supine and the UAP is placing because the use of pillows could result in suffocation and would need to be removed
soft pillows along the side rails. What action at the onset of the seizure. The nurse can delegate paddling the side rails to the UA
should the nurse implement?
a. Ensure that the UAP has placed the pillows
effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to
secure to the side rails instead of pillows.
c. Assume responsibility for placing the
pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to
prop the client in a side lying position.
An adolescent with major depressive Describes life without purpose
disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that
assessment finding requires immediate is known to increase the risk of suicidal thinking in adolescents and young adults with
follow-up major depressive disorder. B, C and D are side effects
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
,A 60-year-old female client with a positive Further evaluation involving surgery may be needed
family history of ovarian cancer has
developed an abdominal mass and is being Rationale: An abdominal mass in a client with a family history for ovarian cancer should
evaluated for possible ovarian cancer. Her be evaluated carefully
Papanicolau (Pap) smear results are negative.
What information should the nurse include in
the client's teaching plan
a. Further evaluation involving surgery may
be needed
b. A pelvic exam is also needed before
cancer is ruled out
c. Pap smear evaluation should be continued
every six month
d. One additional negative pap smear in six
months is needed.
A client who recently underwent a Teach tracheal suctioning techniques
tracheostomy is being prepared for
discharge to home. Which instructions is Rationale: Suctioning helps to clear secretions and maintain an open airway, which is
most important for the nurse to include in critical.
the discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy
site.
In assessing an adult client with a partial Document the assessment data
rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate Rational: reservoir bag should not deflate completely during inspiration and the client's
completely during inspiration and the client's respiratory rate is within normal limits.
respiratory rate is 14 breaths / minute. What
action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
, During shift report, the central Respiratory apnea of 30 seconds
electrocardiogram (EKG) monitoring system
alarms. Which client alarm should the nurse Rationale: The priority is the client whose alarm indicating respiratory apnea that should
investigate first? be assessed first.
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every
minute
d. Disconnected monitor signal for the last 6
minutes.
During a home visit, the nurse observed an Check the client for lacerations or fractures
elderly client with diabetes slip and fall.
What action should the nurse take first? Rationale: After the client falls, the nurse should immediately assess for the possibility of
injuries and provide first aid as needed
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or
fractures
d. Asses clients blood sugar level
At 0600 while admitting a woman for a Inform the anesthesia care provider
schedule repeat cesarean section (C-
Section), the client tells the nurse that she Rationale: Surgical preoperative instruction includes NPO after midnight the day of
drank a cup a coffee at 0400 because she surgery to decrease the risk of aspiration should vomiting occur during anesthesia.
wanted to avoid getting a headache. Which While it is possible the C-section will be done on schedule or rescheduled for later in
action should the nurse take first? the day, the anesthesia provider should be notified first.
a. Ensure preoperative lab results are
available
b. Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d. Contact the client's obstetrician.
After placing a stethoscope as seen in the Listen with the bell at the same location
picture, the nurse auscultates S1 and S2 heart
sounds. To determine if an S3 heart sound is Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds such
present, what action should the nurse take as S3 and S4. The nurse listens at the same site using the diaphragm the diaphragm and
first bell before moving systematically to the next sites.
a. Side the stethoscope across the sternum.
b. Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d. Observe the cardiac telemetry monitor
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