EXIT HESI

Question 1

school nurse called to soccer field for child with nose bleed. what position should nurse place child

Accepted Answer

sitting up leaning forward

Question 2

pt with slit wrists r sutured from recent suicide attempt. which nursing dx is highest priority?

Accepted Answer

risk for self directed violence related to impulsive actions

Question 3

nurse edu on select foods for child with phenylketonuria (PKU). which foods are contraindicated

Accepted Answer

foods sweetened with aspartame

Question 4

after the nurse witnesses preop pt sign surgical consent + nurse signs form as witness. legal implications of nurses sig

Accepted Answer

pt voluntarily grants permission for the procedure to be done, pt understands the risks and benefits assoc with the procedure, pt is competent to sign the consent w/o impairment of judgment

Question 5

rn assess 78 yr old M LHF what s/s would nurse expect pt to exhibit

Accepted Answer

dyspnea, cough, fatigue

Question 6

pt w hx of HF presents w N, V yellow vision n palpitations. which finding is most important for nurse to assess

Accepted Answer

obtain a list of meds taken for cardiac hx

Question 7

pt with which type of wound is most likely to need immediate intervention by the nurse?

Accepted Answer

laceration

Question 8

elderly pt confused reports onset of nausea dysuria and urgency w incontinence. which action should nurse implement

Accepted Answer

obtain a clean catch mid stream specimen

Question 9

pt admit to isolation w dx of TB. which infection control measures should nurse implement

Accepted Answer

negative pressure environment

Question 10

RN plans care for a pt admit w dx pheochromocytoma which intervention has the highest priority for inclusion

Accepted Answer

monitor blood pressure frequently

Question 11

UAP reports pt has weak pulse with rate of 44bpm. what action should charge nurse implement

Accepted Answer

assign LPN to determine if apical radial deficit is present

Question 12

F pt anxious post informed of abnormal mammogram pt cry her mom died breast cancer. nurse action?

Accepted Answer

encourage pt to cont expressing fears and concerns

Question 13

adolescent w major depressive d/o taking duloxtetine for 12 days. which assessment requires immediate follow up?

Accepted Answer

describes life without purpose

Question 14

what pathophysiological mechanism are responsible for ascites r/t liver failure? SATA

Accepted Answer

increased hydrostatic pressure increases fluid into abdomen, fluid shifts from intravascular to interstitial d/t decreased serum protein, increased circulatin aldosterone lvl that increase sodium n water retention

Question 15

what explanation is best for the nurse to provide a pt who asks purpose of using log rolling technique for turning

Accepted Answer

technique is intended to maintain straight spinal alignment

Question 16

which intervention should nurse include in long term care for COPD pt

Accepted Answer

reduce risk factors for infection

Question 17

assessing pt w partial rebreather mask o2 reservoir bag does not deflate during inspiration RR 14b/m. what action?

Accepted Answer

document assessment data

Question 18

which bfast indicates pt understands dietary mngmnt of osteoporosis?

Accepted Answer

bagel with jelly and skim milk

Question 19

before first surgical case of day nurse asks if 3 min surgical hang scrub is adequate in prep for this pt?

Accepted Answer

direct nurse to continue the surgical hand scrub for a 5 min duration

Question 20

F admit w end stage pul disease wants no heroic measures taken if she stops breathing. ask the pt to discuss DNR w HCP?

Accepted Answer

True

Question 21

to determine if an S3 sound is present what action should the nurse take first

Accepted Answer

listen with the bell at the same location

Question 22

at 0600 when admitting for C section pt says she drank cup of coffee at 0400. what action should nurse take first?

Accepted Answer

inform the anesthesia care provider

Question 23

during home visit diabetes pt slips and falls. what action should nurse take first

Accepted Answer

check pt for lacerations or fractures

Question 24

pt receiving chemo has neutropenia. which snack is best for the nurse to recc to pt

Accepted Answer

baked apples topped with dried raisins

Question 25

pt takes oral tetracycline complains of GI upset. nurse tells pt to eat toastedwheatbread&jelly w tetra

Accepted Answer

True

Question 26

charge of CCU low staffed for the day. in planning assignments which pt receives most care hours by an RN

Accepted Answer

82 yo w alzheimers new fracture femur w foley + soft restraints

Question 27

public health nurse funds initiation of primary prevention program in community which 1 best fits the proposal of RN

Accepted Answer

vitamin supplements high risk pregnant women

Question 28

male type 1 DM abdomin cramps and vomiting lethargic mod confused cant remember last dose of insulin / ate last. action?

Accepted Answer

start IV infusion of normal saline

Question 29

pt underwent tracheostomy prep for d/c. which instructions most important for nurse to include in d/c plan?

Accepted Answer

teach tracheal suctioning techniques

Question 30

mother says adolescent has athletesfoot have applied tripleantibioticointment for 2 days w no improvement what instruct?

Accepted Answer

stop using ointment encourage complete drying of feet n wearing clean socks

Question 31

which pt is at greatest risk for dev delirium

Accepted Answer

adult who cannot sleep due to constant pain

Question 32

F loss LOC in ED assessed critically low blood glucose lvls pt reports dx anorexia nervosa. intervention important 4 d/c

Accepted Answer

encourage low carb and high protein diet

Question 33

post lumbar puncture pt complains. which complaint indicated to the nurse that pt is experiencing a complication

Accepted Answer

i have a headache that gets worse when i sit up

Question 34

full strength cont enteral tube feeding at 50 ml/hr + has dev diarrhea script to chnge feed to 1/2 strength intervention

Accepted Answer

add equal amts of water + feeding to a feeding bag + infuse at 50ml/hr

Question 35

RN notes pt has been receiving hydromorphone (Dilaudid) q6hr for 4 days. what assessment most important

Accepted Answer

ascultate pt bowel sounds

Question 36

septic shock DLCVC 1L NS @ 50ml/hr thru 1 port. new IV prepd 45 min infuse rate what intervention?

Accepted Answer

use second port of the normal saline solution to admin antibiotic

Question 37

HCP prescribes IV Isuprel 1 mg in 250 ml at 300 mcg/hr. nurse should program pump to deliver how many ml/hr?

Accepted Answer

75

Question 38

interventions to implement when monitoring pt during seizure

Accepted Answer

move obstacle away from pt, monitor physical movements, observe for a patent airway, record the duration of the seizure

Question 39

nurse conducts physical assessment of young adult. what info provides best indication of pt nutritional status

Accepted Answer

condition of hair nails and skin

Question 40

which action should the school nurse take first when conduction a screening for scoliosis

Accepted Answer

inspect for symmetrical shoulder height

Question 41

3 week old breastfed infant mother has increasing anxiety bc d/c antianxiety meds due to breastfeeding. nurses response

Accepted Answer

inform her that some antianxiety meds are safe to take while breastfeeding

Question 42

pt drowsy but responding to verbal stimuli + reports recently spitting up blood. what assessment warrants intervention?

Accepted Answer

capillary refill of 8 seconds

Question 43

UAP positions pt w seizure disorder. pt supine UAP places pillows on side rails. what action should nurse implement?

Accepted Answer

instruct UAP to obtain soft blankets to secure to the side rails

Question 44

F pt hair becomes coarse + breaks off, outer part of her brows disappeared, + eyes puffy. which follow up question?

Accepted Answer

have you noticed any changes in your fingernails

Question 45

to eval effectiveness of male pt ezetimibe which action should nurse implement?

Accepted Answer

remind pt to keep apt to have cholesterol checked

Question 46

26 yo M admin for tx simple goiter levo sodium (synthroid) prescribed. which symptoms indicate dosage is too high

Accepted Answer

palpitations and SOB

Question 47

66 yo woman retired will not have health insurance through employer. which agency should pt be referred to?

Accepted Answer

medicare

Question 48

Fortax 35 mg q 8 hr for infant. vial 500 mg add 5.3 ml diluent to provide concentration of 100 mg/ml. how many ml/dose?

Accepted Answer

0.4

Question 49

male reports onset of numbness and tingling in fingers and around mouth. which lab should nurse review b4 contact HCP

Accepted Answer

serum calcium

Question 50

most important area of instruction to include in pt edu in regards to decreased bone density n elder: fall precautions

Accepted Answer

True

Question 51

F pt taking high dose of prednisone after stopping abruptly pt feels v tired which intervention is most important

Accepted Answer

measure vital signs

Question 52

which location as best for beginning screening program for hypothyroidism

Accepted Answer

business and prof womens group

Question 53

pt reports no bowel movement for 3 days but now small liquid loose stools nurse digitally checks the pt for fecal impact

Accepted Answer

True

Question 54

d/c care male cancer pt returnin to work w pain n impendin deaf. what goals 4 pt care care plan

Accepted Answer

maintain pain lvl > 4 when implementing outpatient pain clinic strategies

Question 55

6 yo rusty nail went thru shoe and pierced foot what does nurse do first

Accepted Answer

cleanse foot with soap and water and apply antibiotic ointment

Question 56

pt w cervical cancer insertion of radiation implant the nurse finds the radiant implant in the bed. what action by nurse

Accepted Answer

place the implant in a lead container using long handled forceps

Question 57

what is the most likely explanation for failure to locate the gallbladder by palpation?

Accepted Answer

gallbladder is normal

Question 58

when caring for a pt who has ARDS nurse elevates HOB 30 degrees. what is the reason for this intervention

Accepted Answer

to reduce abdominal pressure on the diaphragm

Question 59

EKG alarm sounds which alarm should nurse interpret first?

Accepted Answer

respiratory apnea of 30 seconds

Question 60

60 yr woman + fam hx ovarian cancer w abdominal mass pap negative what info should nurse include in pt teaching plan

Accepted Answer

further eval involving surgery may be needed

Question 61

male w duodenal ulcer says he will drink diary to coat his ulcer. what is best follow up action by nurse?

Accepted Answer

review with the client need to avoid foods that are rich in milk and cream

Question 62

diabetes edu program. what goal should b primary emphasis for class on diabetes management

Accepted Answer

enable pt active participation in controlling disease process

Question 63

which instruction should nurse provide a pregnant pt who is complaining of heartburn

Accepted Answer

eat small meal throughout day to avoid full stomach

Question 64

HTN pt BP 158/106 admits to not taking meds they make him feel bad. stress that high BP places pt at risk for what?

Accepted Answer

stroke secondary to hemorrhage

EXIT HESI

Questions 70

EXIT HESI

Questions 70