366 EXIT HESI EXAM TEST WITH VERIFIED ANSWERS GRADED A+
A newly admitted client complains of
pain rating a 7 on a scale of 0 to 10. The Correct Answer:
client has not been sleeping well lately 1.Airway and breathing. 2.Pain manage-
and is experiencing labored breathing. ment. 3.Sleep and rest. 4.Definitive ther-
List the client's problems in order of pri- apy.
ority for the nurse. (Rank in the priority Rationale
order from highest to lowest.)
1. First-level problems are immediate prior-
Airway and breathing. ities (airway, breathing, and circulation).
2. In this scenario, airway and breathing are
Pain management. the first priority, followed by pain man-
3. agement, Maslow's hierarchy of basic
Definitive therapy. needs for rest and sleep, and then defin-
4. itive drug therapies.
Sleep and rest.
3. Blood-borne pathogen standard.
5. Resource Conservation and Recovery
Which biological practices are federally
Act (RCRA)
regulated for healthcare workers? (Se-
lect all that apply.)
Basic standards for healthcare workers,
Select all that apply
as delineated by Occupational Safety
1. Standard precautions.
and Health Administration (OSHA), in-
clude standard precautions, droplet pre-
2. N-95 tuberculosis standard.
cautions using N-95 respiratory particu-
3. Blood-borne pathogen standard.
late masks when caring for a client who
4. Biological product exposure limit
is positive for tuberculosis, and required
(BPEL).
annual updates for healthcare work-
5. Resource Conservation and Recovery
ers about blood-borne pathogen trans-
Act (RCRA).
mission, methods of minimizing expo-
6. As Low as Reasonably Allowable stan-
sure, and employee rights. Other options
dard (ALARA).
[BPEL and ALARA ] are not federally
regulated.
A client with severe depression tells the 3. "I have known many clients with de-
nurse, "I do not know why you bother with pression who have felt better after sever-
me or give me pills. I am never going to al weeks of treatment."
get well." What is the most therapeutic
response? Stating the observation that others have
1. "You need to stop thinking negative recovered can give a client hope. Telling
, 366 EXIT HESI EXAM TEST WITH VERIFIED ANSWERS GRADED A+
thoughts. They get in the way of your
a person to stop negtive thinking is in-
recovery."
effective because the client must be
2. "You are no bother to me or to the staff.
taught cognitive strategies to stop neg-
We want you to get well and not feel sad
ative thinking. Stating the person is "no
anymore."
bother" is arguing with the client's be-
3. "I have known many clients with de-
liefs and attempting to tell him how to
pression who have felt better after sever-
feel, both of which are not therapeutic
al weeks of treatment."
responses. Bring up pessimistic feelings
4. "You are feeling very pessimistic, but
interprets the client's feelings and does
that is part of your illness. It should go
not provide the same degree of hope.
away as you recover."
The nurse is caring for a client with a
nursing problem of, "Infection, risk for, re-
lated to inadequate primary defenses as
evidenced by surgical incision and IV ac- 3. Assess and document skin condition
cess." What nursing intervention should around the incision and IV site at each
the nurse implement? shift.
1. Limit visitors to immediate family to
decrease exposure to infection. Early identification of infection leads to
2. Maintain "clean" technique in the prompt treatment and decreased noso-
change of wound dressing and IV site. comial transmission to others, so the
3. Assess and document skin condition condition of any invasive lines or breaks
around the incision and IV site at each in the skin should be assessed and doc-
shift. umented during each shift.
4. Require the use of a face mask by
staff when providing care requiring close
contact.
4. Stool is eventually expelled through
A client with ulcerative colitis is sched- the rectum.
uled for surgical creation of an ileoanal
reservoir (J pouch). As part of preoper-
ative teaching, what information should An ileal pouch-anal anastomosis (also
the nurse provide? known as the J pouch) is a surgical-
1. The transverse loop ostomy is perma- ly created ileoanal reservoir in the anal
nent. canal that preserves the rectal sphincter
2. Easily removable appliances allow in- muscle, so that passage of stool through
dependence in self-care. the rectum is the eventual result. To pro-
mote healing of the anastomosed parts
, 366 EXIT HESI EXAM TEST WITH VERIFIED ANSWERS GRADED A+
of the colon, a temporary loop ostomy is
created, not a permanent one. Although
3. Daily irrigation is started after the J
appliances that are easy to use are ad-
pouch heals.
vantageous, the ostomy is reversed after
4. Stool is eventually expelled through
healing takes place. Stool drains into the
the rectum.
reservoir, so daily irrigation is not usually
indicated.
The nurse inflates the cuff on a tra- 4. Inject air until no air is auscultated over
cheostomy tube to minimal occlusion the larynx during a deep breath.
pressure for a client who is breathing
spontaneously. Which action should the To achieve minimal pressure (minimal
nurse follow? occlusion volume technique) against the
1. Check the pilot balloon to ensure that tracheal wall, inject air into the tra-
it is firm. cheostomy tube cuff while auscultating
2. Verify the healthcare provider's pre- with a stethoscope placed over the lar-
scription for the required cuff pressure. ynx (over the cuff) during inhalation. At
3. Use a manometer to maintain cuff the point when sounds of air movement
pressure between 25 and 30 mmHg. cease, inflation is stopped, indicating
4. Inject air until no air is auscultated over that the cuff is sealed against the tra-
the larynx during a deep breath. cheal wall.
1. Refer for further diagnostic evaluation.
A 60-year-old homeless man who com-
The PPD skin test results is indicative of
plains of a cough, late-afternoon fever,
exposure or latent Mycobacterium tuber-
and night sweats has a 10 mm induration
culosis infection (LTBI), which this client
after receiving a purified protein deriva-
is in a high-risk category for exposure
tive (PPD) skin test. Which action should
in a homeless environment. Although
the nurse implement?
productive prolonged cough, fever, and
1. Refer for further diagnostic evaluation.
night sweats are common early symp-
2. Determine exposure of others to the
toms, persons suspected of LTBI should
tuberculosis.
3. Begin anti-tubercular drug therapy. not begin treatment until active TB dis-
ease has been excluded. Further diag-
4. Quarantine or isolate to control com-
nostic evaluation should be implement-
municability.
ed. A dormant form that neither causes
disease nor is communicable.
, 366 EXIT HESI EXAM TEST WITH VERIFIED ANSWERS GRADED A+
1. Economics.
3. Technology.
6. Legislation/regulation.
Economics affects the health of the com-
Which contextual factors are considered pany and its workforce productivity, in
external environmental influences in the termsof profitability, growth, and expan-
framework for occupational health pro- sion. Technology adds to an industry's
grams and services? (Select all that ap- capacity to develop and implement new
ply.) or improved work processes. Legisla-
Select all that apply tion/regulation in the workplace, such as
1. Economics. the blood-borne pathogen standard, af-
2. Workforce. fects the workforce in terms of require-
3. Technology. ments, administration, and control strate-
4. Interventions. gies. Occupational safety programs are
5. Socio-economic status. built around the workforce to strive for
6. Legislation/regulation. maximum internal productivity. Interven-
tions are internal environmental influ-
ences of an occupational health and
safety program. Socio-economic status
is a demographic variable commonly
used in epidemiology.
4. QRS interval of 0.14 second.
The nurse is analyzing the waveforms of
a client's electrocardiogram. What find-
The normal duration of the QRS is 0.04
ing indicates a disturbance in electrical
to 0.12 second, so a prolonged QRS in-
conduction in the ventricles?
dicates an electrical anomaly in the ven-
1. T wave of 0.16 second.
tricles. The T wave is normally 0.16 sec-
2. PR interval of 0.18 second.
onds. The PR interval range is 0.12 to
3. QT interval of 0.34 second.
0.20 second. The QT interval should be
4. QRS interval of 0.14 second.
0.31 to 0.38 second.
The nurse is assigned a client with nu-
2. Prioritize tasks with the most crucial
merous treatments and decides it is
needs first.
not possible to complete all the needed
treatments in the time scheduled for this
Planning care for a client with numer-
shift. Which process should the nurse
ous treatments should be prioritized with
use?
the most crucial client needs first to the
1. Delegate tasks to competent team
