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ALL HESI EXIT QBANK / ATI EXAMS TEST BANK QUESTIONS AND ANSWERS
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ALL HESI EXIT QBANK / ATI EXAMS TEST BANKQUESTIONS AND ANSWERS
271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO
daily at bedtime. What action should the nurse take?
Correct Ans ~ Administer the medication as prescribed with a glass of
water
272. Which client should the nurse assess frequently because of the risk for
overflow incontinence? A client
Correct Ans ~ Who is confused and frequently forgets to go to the
bathroom
273. While monitoring a client during a seizure, which interventions should
the nurse implement? (Select all that apply)
Correct Ans ~ Move obstacle away from client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure
274. 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 stopped smoking 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? Correct Ans ~ Observe for changes in
level of consciousness.
275. 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 respiratory rate 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?
Correct Ans ~ Increase ventilator rate.
276. 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?
Correct Ans ~ CPT should be performed more frequently, but at least an
hour before meals.
277. The nurse is evaluating the diet teaching of a client with hypertension.
What dinner selection indicates that the client understands the dietary
recommendation for hypertension?
,Correct Ans ~ Baked pork chop, applesauce, corn on the cob, 2% milk, and
key-lime pie
278. 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?
Correct Ans ~ Fingerstick glucose assessment q6h with meals
Review with the client proper foot care and prevention of injury
Coordinate carbohydrate controlled meals at consistent times and intervals
Teach subcutaneous injection technique, site rotation and insulin
management
279. Which problem reported by a client taking lovastatin requires the most
immediate fallow up by the nurse?
Correct Ans ~ Muscle pain
280. 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?
Correct Ans ~ Provide supplemental oxygen
Auscultate bilateral lung fields
Reinforce occlusive CT dressing
281. Before leaving the room of a confused client, the nurse notes that a half
bow knot was 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?
Correct Ans ~ Ensure that the knot can be quickly released.
282. 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?
Correct Ans ~ Have the child lie with the ear up for one to two minute after
installation.
283. 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?
,Correct Ans ~ Restrict daily fluid intake.
284. The nurse inserts an indwelling urinary catheter as seen in the video
what action should the nurse take next?
Correct Ans ~ Leave the catheter in place and obtain a sterile catheter.
285. 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)?
Correct Ans ~ Prepare the skin for procedure.
286. Fallowing an outbreak of measles involving 5 students in an elementary
school, which action is most important for the school nurse to take?
Correct Ans ~ Restrict unvaccinated children from attending school until
measles outbreak is resolved.
287. A preeclamptic client who delivered 24h ago remains in the labor and
delivery recovery room. She continues to receive magnesium sulfate at 2
grams per hour. Her total input is limited to 125 ml per hour, and her urinary
output for the last hour was 850 ml. What intervention should the nurse
implement?
Correct Ans ~ Continue with the plan of care for this client
288. The nurse is planning care for a client who admits having suicidal
thoughts. Which client behavior indicates the highest risk for the client
acting on these suicidal thoughts? Correct Ans ~ Begin to show signs of
improvement in affect
289. When assessing a multigravida the first postpartum day, the nurse finds
a moderate amount of lochia rubra, with the uterus firm, and three
fingerbreadths above the umbilicus. What action should the nurse implement
first?
Correct Ans ~ Check for a destined bladder
290. A 12 year old client who had an appendectomy two days ago is
receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity
is 1.035. What action should the nurse implement?
Correct Ans ~ Encourage popsicles and fluids of choice
291. An older male client arrives at the clinic complaining that his bladder
always feels full. He complains of weak urine flow, frequent dribbling after
voiding, and increasing nocturia with difficulty initiating his urine stream.
Which action should the nurse implement? Correct Ans ~ Palpate the
client's suprapubic area for distention
, 292. The nurse is preparing to administer 1.6 ml of medication IM to a 4
month old infant. Which action should the nurse include?
Correct Ans ~ Divide the medication into two injection with volumes under
1ml
293. A client who had a below the knee amputation is experiencing severe
phantom limb pain (PLP) and ask the nurse if mirror therapy will make the
pain stop. Which response by the nurse is likely to be most helpful?
Correct Ans ~ Research indicates that mirror therapy is effective in
reducing phantom limb pain
294. An older adult client with heart failure (HF) develops cardiac
tamponade. The client has muffled, distant, heart sounds, and is anxious and
restless. After initiating oxygen therapy and IV hydration, which intervention
is most important for the nurse to implement?
Correct Ans ~ Notify healthcare provider to prepare for pericardiocentesis
295. A new member joins the nursing team spreads books on the table, puts
items on two chairs, and sits on a third chair. The members of the group are
forced to move closer and remove their possessions from the table what
action should the nurse leader take? Correct Ans ~ Ask the new person to
move belonging to accommodate others
296. The nurse is caring for a one week old infant who has a
ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which
findings are an indication of a postoperative complication?
Correct Ans ~ Poor feeding and vomiting
Leakage of CSF from the incisional site
Abdominal distention
297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client
who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o
ml multidose vial with the concentration of 1,000 USP units/ml. how many ml
of heparin should the nurse administer? (Enter numeric value only)
Correct Ans ~ 8
298. In monitoring tissue perfusion in a client following an above the knee
amputation (aka), which action should the nurse include in the plan of care?
Correct Ans ~ Evaluate closet proximal pulse.
299. The leg of a client who is receiving hospice care have become mottled
in appearance. When the nurse observes the unlicensed assistive personal
(UAP) place a heating pad on the mottled areas, what action should the
nurse take?
Correct Ans ~ Remove the heating pads and place a soft blanket over the
client's leg and feet.
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