= HESI RN EXIT EXAM COMPREHENSIVE V1-2021 ACTUAL EXAM
= The nurse is reviewing medical prescriptions for newly admitted clients. It would be a priority for the nurse to follow up with the physician if a client with A. A potassium of 4.5 mEq/L has Kayexalate (sodium polystyrene) prescribed B. Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions C. Sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen) D. Sensitivity to Penicillin is prescribed Zithromax (azithromycin)
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse should intervene if the nurse notes a staff member Obtaining a clients consent prior to their operative procedure after receiving Ativan (lorazepam) B. Placing a client on the affected side following surgical repair of a retinal detachment C. Handling a wet cast with the palms of the hands D. Using a broad base of support while transferring a client A.
ACADEMICMA STER HESI RN EXIT EXAM 2021 The community health nurse is caring for the following clients. It would be a priority for the nurse to initiate a multidisciplinary conference for the client who is A. 12 years old with Autism who is starting a new school and recently had a URI (upper respiratory tract infection) yeaBr.s old, has type 1 Diabetes Mellitus, and a recent Hemoglobin A1c of 1 C. 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and employed as a mail carrier D. 70 years old, has schizophrenia, lives alone and reports hearing non threatening voices.
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse from the postpartum unit has been temporarily assigned to the medical surgical unit. It would be most appropriate to assign this nurse to the client who A. has returned from right total hip replacement surgery four hours ago B. is being observed for increased intracranial pressure C. had surgery two hours ago to remove the appendix D. is two weeks post partum being maintained on a mechanical ventilator for respiratory failure
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse in a well baby clinic has assessed several children today. It would be a priority for the nurse to suggest follow up for the child who is A. 2 months old with a positive babinski reflex B. 4 months old and does not hold their own bottle C. 10 months old who cries around strangers D. 18 months old who needs support while ambulating
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ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a mechanically ventilated client who was declared brain dead. An Advance Directive is not documented on the medical record. It would be most appropriate to obtain consent for organ donation from the A. client9s primary care provider B. client9s nurse manager C. closest living family member D. hospital9s ethics committee
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has received report on four clients. The nurse should first assess the client who has: A. Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90% B. Parkinson9s Disease and is demanding to leave the hospital against medical advice (AMA) C. D. Heart Failure (CHF) whose pitting edema has increased to 2(+) E. Retinal detachment and is complaining of dark floating spots Guillian Barre Syndrome and has begun plasmapheresis therapy
One-on-one client observation for safety ACADEMICMA STER HESI RN EXIT EXAM 2021 It would be appropriate to assign which of these tasks to the CNA? A. Feeding a client who is experiencing dysphagia B. C. Ambulating a post-op patient for the first-time D. Performing a dressing change
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse should intervene if a staff member is observed: A. Discussing a client9s diagnosis with visiting family members B. Collaborating with another nurse to review a prescription for blood transfusion C. Interrupting other staff members discussing a client in the cafeteria D. Reviewing a clients lab values with the nutritionist
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse would be correct to include which of the following examples? A. Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is false imprisonment B. Telling a client that you will put in a feeding tube if the client does not eat is an example of battery C. Telling a client with bipolar disorder who is suicidal that they have a right to refuse to take their medications is an example of malpractice D. Placing hands on a client who says <do not touch me= is an example of assault
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse from the pediatric unit has been temporarily assigned to the Emergency Department. It would be most appropriate to assign that nurse to the client who A. Reports epigastric pain that <feels like indigestion= B. Has back pain and a pulsating abdominal mass C. Is HIV+ reporting vomiting and diarrhea D. Presents with lower abdominal pain and is six weeks pregnant
ACADEMICMA STER HESI RN EXIT EXAM 2021 Four clients recently returned to the unit following invasive diagnostic testing. The nurse should immediately intervene if one of the clients: A. Reports blood tinged sputum following a bronchoscopy B. Has decreased abdominal girth following paracentesis C. Reports a headache following a lumbar puncture D. Is observed flexing and extending the legs two hours after cardiac catheterization
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is made aware of the following situations. The nurse should first check the client who A. Had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours after the indwelling catheter is removed B. Has cervical traction and is moving the legs by flexing and extending the feet C. Has Alzheimer9s disease (stage 1) and was returned to the room after being found wandering in the hallway hiDst.ory of partial seizures and is sitting in the bed picking at the clothing and smacking th
<I can feed my child oatmeal and eggs for breakfast= ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse in a community health clinic is talking with the parent of a child with Celiac Disease. Which of the following statements would require follow-up by the nurse for additional teaching? A. <This weekend we are going to a seafood restaurant= B. C. <My child loves to eat rice and chicken for dinner= D. <Last night we ate fish with corn for dinner=
ACADEMICMA STER HESI RN EXIT EXAM 2021 The charge nurse is observing a Licensed Practical Nurse (LPN) performing care for assigned clients. Follow up will be required if the LPN: A. Assesses a client9s apical pulse for 60 seconds before administering Digoxin B. Completes an incident report for a client that has a pair of eyeglasses missing C. Dons a clean glove on the dominant hand before tracheal suctioning D. Positions a client on the operative side following a pneumonectomy
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse at a health promotion fair has taught a group of parents about car seat and seat belt safety. Which of the following statements, if made by the parent, would indicate a correct understanding of the information given? A. <I will place my newborn infant in a rear facing car seat in the middle of the rear seat.= B. <I will wear a lap seat belt high on my belly since I am 8 months pregnant.= C. <I can use a front-facing car seat once my baby weighs 15 pounds.= D. < I can allow my six-year-old to use a seat belt in the front passenger seat=
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client being treated for Vancomycin Resistant Enterococcus (VRE). The nurse should place the client on A. Contact precautions B. Droplet precautions C. Protective precautio ns D.Airborne precautions
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client with a Vancomycin Resistant Enterococcus (VRE) wound infection. Which of the following actions would be appropriate for the nurse to take? A. Wear a particulate respirator mask when providing wound care B. Instruct visitors not to bring flowers into the client9s room C. Place the client in a private room with negative air pressure D. Wear a disposable gown when changing the client9s dressing
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse should initiate protective precautions for a client who has a A. Red Blood Cell Count (RBC) of 3,900/mm3 B. Platelet count of 400,000μ/L C. Hemoglobin (Hgb) 9.0 g/dl D. White Blood Cell Count (WBC) 2,500/mm3
<I am glad that I can still clean my parakeet’s cage= ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has provided health promotion teaching for a group of clients who were recently diagnosed with the Human immunodeficiency virus (HIV). Which statement, if made by one of the clients, would require further teaching? A. B. <I will not go to the parade this weekend= C. <I will increase protein in my diet= D. <I will miss not being able to work in my garden
Has soot on the face and the nares and is coughing ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse in the emergency department is caring for disaster clients admitted following a rescue from a burning bus. The nurse should first see the client who A. Has the tibia bone protruding through the skin and is in severe pain B. Has third degree burns of the left foot and is crying C. Is unconscious, pulseless, and has dilated pupils D.
ACADEMICMA STER HESI RN EXIT EXAM 2021 A nurse is observing a newly-hired nurse provide care for assigned clients. The nurse should follow up if the newly- hired nurse is observed A. Wearing gloves when taking the blood pressure of a client with disseminated varicella zoster Cleansing the wound from the outer surface to the inner surface for a client whose wound is infected with a multi- drug resistant organism C. Opening the flap away from the body of a sterile package first. D. Removing the gloves before removing the gown when leaving a room of a client who is on contact precautions B
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client who has been diagnosed with rheumatoid arthritis. The nurse should anticipate that the client will initially be prescribed A. B. Disease-modifying rheumatic agents C. Biologic Response Modifiers D. Long-term corticosteroids Nonsteroidal anti-inflammatory drugs (NSAIDs)
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is assessing a 2-month-old-infant at a well baby clinic. The nurse should anticipate the infant should A. Roll from prone to back B. Have no head lag C. Smile socially D. Have no tonic neck reflex
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is teaching a class on infant nutrition. The nurse should instruct parents to introduce A. Fruit juices at 3 months B. Honey sweetened water at 5 months C. Pureed chicken at 7 months D. Whole milk at 9 months
A board game ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a 7-year-old who has thrombocytopenia and is on protective precautions. Which of the following would be an appropriate toy for the nurse to provide to the client? A. Finger paints and paper B. A rubber ball and bat C. D. A stuffed toy
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse on a pediatric unit has been informed that the following clients are being admitted. The nurse should first plan to assess the client who is 2 yAe.ars old, has a temperature of 100.8 F and a blood pressure of 68/44 B. 4 years old with a history of asthma and has a peak expiratory flow rate (PERF) of 81% C. 5 years old, has a fracture of the tibia and is reporting pain rated 7 on a pain scale of 0 (no pain) to 10 (severe pain) D. 7 years old with ulcerative colitis and has had 15 bloody tinged stools today
C. ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is assessing a 3-year-old during a well-child visit. During the visit the boy says to his mother, <Mommy, I love you. I9m going to marry you=. The nurse should A. Suggest to the mother not to encourage these types of statements B. Explain to the child that he will not be able to marry his mother even though he loves her Tell the mother that this statement is appropriate for his stage of development D. Recommend that the mother provide more opportunities for her son to play with other 3- year-old boys
ACADEMICMA STER HESI RN EXIT EXAM 2021 The mother of an infant tells the nurse that the baby has not been tolerating feedings lately and she noticed an olive-shaped mass in the infant9s abdomen. The nurse recognizes that this could be an expected finding if the infant has A. Intussusception B. Hirschsprung9s disease C. Umbilical hernia D. Pyloric stenosis
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is teaching a group of parents about the expected growth and development of three-year-old children. The nurse should include that a three-year- old should A. Discriminate between fantasy and reality B. Ride a tricycle independently C. Have a vocabulary of 7,000 words D. Play in a group of two or three with one being the leader
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse and the nursing assistant are caring for a group of clients. Which of the following client care activities should the nurse assign to the nursing assistant? Select all that apply. A. reinforcing the dressing of a client who has a decubitus ulcer B. monitoring the vital signs of a client who had a myocardial infarction 12 hours ago and is being transferred from the coronary care unit C. administering a tap water enema to a client who will undergo a colonoscopy in two hours D. placing a client who had an above the knee amputation 24 hours ago in a prone position E. assisting a client who had a colon resection 36 hours ago to ambulate F. showing a client who had a vaginal hysterectomy 36 hours ago how to perform perineal care
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse and the nursing assistant are caring for a group of clients. Which of the following client care activities should the nurse assign to the nursing assistant? Select all that apply. A. reinforcing the dressing of a client who has a decubitus ulcer B. monitoring the vital signs of a client who had a myocardial infarction 12 hours ago and is being transferred from the coronary care unit C. administering a tap water enema to a client who will undergo a colonoscopy in two hours D. placing a client who had an above the knee amputation 24 hours ago in a prone position E. assisting a client who had a colon resection 36 hours ago to ambulate F. showing a client who had a vaginal hysterectomy 36 hours ago how to perform perineal care
an abdominal hysterectomy yesterday and is reporting calf ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has become aware of the following client situations. The nurse should first assess the client who A. Had received a unit of packed red blood cells four hours ago and is requesting a bedpan HaBd. C. Has history of multiple sclerosis and is reporting diplopia D. Had a tonsillectomy three hours ago and is reporting a sore throat pain
ACADEMICMA STER HESI RN EXIT EXAM 2021 The primary health care provider has prescribed Heparin 5000 units SC. The drug available is heparin sodium 7500units/ml. Choose all of the correct answers for nursing considerations for the administration of heparin sodium. A. administer the heparin in the abdomen B. administer 0.5ml of heparin sodium C. aspirate after inserting the needle D. use a 1 inch 21 gauge needle E. refrain from massaging the site after administer heparin F. remember that protamine sulfate is the antidote for heparin
ACADEMICMA STER HESI RN EXIT EXAM 2021 The primary health care provider has prescribed Heparin 5000 units SC. The drug available is heparin sodium 7500units/ml. Choose all of the correct answers for nursing considerations for the administration of heparin sodium. A. administer the heparin in the abdomen B. administer 0.5ml of heparin sodium C. aspirate after inserting the needle D. use a 1 inch 21 gauge needle E. refrain from massaging the site after administer heparin F. remember that protamine sulfate is the antidote for heparin
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has attended a staff development conference on cultural considerations for clients receiving hospice care. Which of the following statements if made by the nurse would require follow-up? A. The family of a client of the Buddhist faith may ask for a priest to be present at the time of death B. The family of a client of the Jewish faith may request to stay with the body after the death of the client C. The family of a client of the Muslim faith may request that the body of the client be turned to face the East at the time of the client9s death
ACADEMICMA STER HESI RN EXIT EXAM 2021 D. The family of a client of the Hindu faith may request that the client9s body be bathed by staff after the client9s death
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client with bipolar disorder who has lithium prescribed. The nurse should suggest that the client have which of the following snacks? A. A fresh fruit cup B. Coffee and oatmeal cookies C. Tuna fish salad on saltine crackers D. Raw vegetables
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has provided discharge instructions for a client who has been prescribed digoxin (Lanoxin). It would require follow up by the nurse if the client says A. <I will consult my primary health care provider before taking medications that contain aspirin.= B. <I will not take any antacids within two hours of taking the digoxin.= C. <I will avoid fruits such as avocados, grapefruit and cantaloupe.= D. <I will remember that any visual disturbance can be a sign of digitalis toxicity.=
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client who has bumetanide (Bumex) prescribed. The nurse should suggest that the client include which of the following foods in the diet? A. Apricots B. Organ meats C. Sardines D.Fish
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is providing teaching for a client with ulcerative colitis. Select all of the following that the nurse should include in the teaching A. steatorrhea commonly occurs or excessive secretion of fecal lipids is common B. ulcerative colitis occurs most frequently in Jewish males 30- 50 years of age C. a diet in high in residue and low in complex carbohydrates is helpful in controlling symptoms D. corticosteroids may be prescribed during an exacerbation E. metronidazole (flagyl) and ciprofloxacin (cipro) are antibiotics commonly used during acute exacerbations
ACADEMICMA STER HESI RN EXIT EXAM 2021 F. eating small frequent meals and lay down after eating promotes absorption of nutrients
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is providing teaching for a client with ulcerative colitis. Select all of the following that the nurse should include in the teaching A. steatorrhea commonly occurs or excessive secretion of fecal lipids is common B. ulcerative colitis occurs most frequently in Jewish males 30- 50 years of age C. a diet in high in residue and low in complex carbohydrates is helpful in controlling symptoms D. corticosteroids may be prescribed during an exacerbation E. metronidazole (flagyl) and ciprofloxacin (cipro) are antibiotics commonly used during acute exacerbations
ACADEMICMA STER HESI RN EXIT EXAM 2021 F. eating small frequent meals and lay down after eating promotes absorption of nutrients
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is precepting a newly-hired nurse who is caring for a client with a tracheostomy. The nurse should intervene immediately if the newly-hired nurse A. Uses half-strength hydrogen peroxide to clean the cannula and rinses with normal saline B. Secures new ties in place before removing soiled ones C. Leaves room for one finger to be placed between the tie tape and the neck D. Cleans the stoma with full-strength hydrogen peroxide
ACADEMICMA STER HESI RN EXIT EXAM 2021 The primary health care provider has prescribed ampicillin (Omnipen) 0.5 GM PO Q6H to a 15 month old toddler who weighs 22 pounds. The drug available is ampicillin suspension 250 mg/5 ml. The recommended dosage is 50 mg/kg/day divided over 3 doses. The nurse should ry heA.alth care provider to report that the prescription exceeds the recom B. Determine if the toddler has previously had a penicillin or a cephalosporin prescribed C. Give the toddler the ampicillin mixed with applesauce D. Wait until the result of the throat culture obtained one hour ago is available
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is preparing a class for parents of children diagnosed with sickle cell anemia. The nurse should instruct the parents to have their children avoid (select all that apply) A. Other children with infections B. Medications containing aspirin C. Contact sports D. Limiting fluids
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is preparing a class for parents of children diagnosed with sickle cell anemia. The nurse should instruct the parents to have their children avoid (Select all that apply) A. Other children with infections B. Medications containing aspirin C. Contact sports D. Limiting fluids
A.Roll from abdomen to back ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is assessing a 5-month-old infant. The nurse should expect the infant to B. Sit without support C. Say 8mama9 and 8dada9 D.Prefer use of one hand over the other
ACADEMICMA STER HESI RN EXIT EXAM 2021 The home health care nurse is assigned to see four clients who all live within three miles of each other. The nurse should first see the client who has A. Gastroesophageal reflux disease (GERD) and is reporting a burning abdominal pain that is relieved by walking CanceBr. of the esophagus who has given away a favorite shirt since the last C. Regional enteritis (Crohn9s disease) who has an elevated temperature and is vomiting D. A gastrostomy tube who will begin self-feeding for the first time
At the same time as a prescribed iron preparation ACADEMICMA STER HESI RN EXIT EXAM 2021 A student nurse is administering magnesium hydroxide/aluminum hydrate (Maalox) prescribed as an antacid to a client. The nursing instructor should intervene if the student plans to administer the antacid A. Two hours after the client has eaten a meal B. C. After briskly shaking the bottle of Maalox D. When assessing the client for the presence of gastric pain
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client who is ventilator dependent. The nurse is aware that the high pressure alarm can be sounded for various reasons. Select all reasons that could apply.. A. increased bronchial secretions B. the presence of an air leak C. the presence of a kink in the tubing D. the client stops breathing spontaneously E. acute bronchospasm F. the client is biting the tube G. the ventilator tubing is disconnected
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client who is ventilator dependent. The nurse is aware that the high pressure alarm can be sounded for various reasons. Select all reasons that could apply. A. increased bronchial secretions B. the presence of an air leak C. the presence of a kink in the tubing D. the client stops breathing spontaneously E. acute bronchospasm F. the client is biting the tube G. the ventilator tubing is disconnected
Document the condition of the stoma ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client who has a new colostomy. The colostomy stoma is red, moist and slightly raised. The nurse should A. Determine if the client is allergic to the skin barrier B. Apply petroleum jelly gauze around the stoma C. D. Assess the client9s temperature
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has attended a staff development conference on Meniere9s Disease. Which of the following statements, if made by the nurse would require follow-up? A. <Meniere’s Disease symptoms result from excess endolymphatic fluid in the inner ear.= B. <Clients with Meniere’s Disease are encouraged to have a low salt diet.= C. <Assistive listening devices are required for clients with Meniere’s Disease.=
ACADEMICMA STER HESI RN EXIT EXAM 2021 D. <Stress is suspected to have a role in Meniere’s Disease.=
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is admitting a client to the emergency department who is reporting visual impairment and loss of peripheral vision. The nurse should recognize that these symptoms are consistent with the medical diagnosis of A. Macular degeneration B. Closed angle glaucoma C. Senile cataract D. Retinal detachment
<BI. will need to instill the prescribed eye drops daily for one week= ACADEMICMA STER HESI RN EXIT EXAM 2021 The new nurse is caring for a patient that has open angle glaucoma. Which of the following statements by the new nurse would require follow-up by the preceptor A. <Open angle glaucoma is the most common type of primary glaucoma= C. <It is important to stay on schedule with my prescribed eye drops= D. <Prescription eyedrops will not improve my lost vision=
Wheezing during expiration ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client who has left ventricular failure. Which of the following should the nurse recognize as being consistent with this diagnosis? A. 3+ pedal edema B. Jugular vein distention C. Oxygen saturation of 96% D.
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has attended a staff development conference on preparing clients for neurological diagnostic tests. Which of the following statements, if made by the nurse would require follow-up? A. <The electromyogram (EMG) is performed by introducing small needle electrodes into muscles.= B. <After having a Positron Emission Tomography (PET) of the head the client can resume normal activities.= roencCe.phalogram (EEG) will require the client to be NPO for 12 hours befo D. <After the lumbar puncture (LP) the client will need to lie flat for about 3 hours.=
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client A. who had a cervical radium implant inserted sixteen hours ago is placed ranssphenoonidbael hdypreopshtysectomy twelve hours ago is drinking fluids throug B. C. who has received prescribed lithium for the past three days is observed eating a pickle brought in by a family member D. who had retinal detachment repaired using a gas bubble four hours ago is lying on the operative side postoperatively
Spinach and rhubarb ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client who has oxalate kidney stones. The nurse should teach the client to avoid A. B. Mushrooms and rice C. Shell fish and aged cheese D. Organ meats and wine
ACADEMICMA STER HESI RN EXIT EXAM 2021 A client with end stage renal disease (ESRD) is scheduled for hemodialysis in one hour. The nurse should notify the primary health care provider that the client has a A. BUN of 60 mg/dl B. Creatinine 3.5 mg/dl C. Sodium 145 mEq/L D. Potassium 6.8 mEq/L
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse at a health clinic is screening male clients for testicular cancer. It would be a priority for the nurse to teach testicular self examination to A. B. A 39-year-old who smokes a pack of cigarettes day C. A 55-year-old with benign prostatic hypertrophy D. A 69-year-old with a family history of testicular cancer A 17-year-old college football player
B.Ego integrity vs. despair ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a 72-year-old client who was recently diagnosed with metastatic breast cancer. The client is expressing feelings of depression and is asking the nurse, <Why me=? According to Erikson, which developmental stage is the client experiencing? A. Industry vs. inferiority C. Generativity vs. stagnation D. Intimacy vs. isolation
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has attended a staff development conference on sexually transmitted diseases. Which of the following statements, if made by the nurse would require follow-up? A. <During the primary stage of syphilis a lesion occurs at the site of infection called a chancre= B. <A client with HIV with a reading of 5mm on the mantoux test is considered to have a positive finding for pulmonary tuberculosis= C. <Gonorrhea is often asymptomatic in women but may cause dysuria and urinary frequency in males= dia is oDft. en symptomatic in women and complications include disseminate
ACADEMICMA STER HESI RN EXIT EXAM 2021 The infection control nurse is making rounds on a Medical Surgical unit. The infection control nurse should immediately intervene if a nurse is observed le sAu. rgical face mask when entering the room of a client with active pulmo B. keeping the door to the room closed of a client with disseminate varicella zoster C. leaving a dedicated stethoscope in the room of a client with respiratory syncytial virus D. wearing a gown, gloves, and mask while taking the blood pressure of a client with Ebola Virus
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse in a community health setting is assessing the following clients. It would be a priority for the nurse to utilize a multidisciplinary approach for the client who is A. 12 years old, with chicken pox and cannot attend school 21 yeaBr.s old, pregnant, unemployed and has active pulmonary tuberculosi C. 32 years old, a grade school teacher and is recovering from a sickle cell crisis D. 74 years old, with mild Alzheimer9s disease and is in an assisted living residence
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse working in the labor and delivery room has become aware of the following client situations. The nurse should first assess the client who is A. In the first phase of labor and the fetal heart rate ranges from 128 to 140 between contractions nd phBa. se of labor and the fetal heart rate is consistently beating at 132 be C. In the third phase of labor and the fetal heart rate has decelerated to its lowest point at the acme of the contraction D. In the third phase of labor and the contractions are lasting 60-70 seconds
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has become aware of the following client situations. It would be a priority for the nurse to follow-up if a client who A. Had a total knee replacement 24 hours ago is using continuous passive motion (CPM) exerciser while in a supine position amB.in 4 hours and states <I can not drink any liquids until 12 hours after th C. Had a total hip replacement 12 hours ago and has an abduction pillow in place D. Had a pin inserted 4 hours ago for a fractured femur has a small amount of bright red bleeding at the pin site
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is teaching a client about crutch walking. Which of the following statements if made by the client indicates a need for further teaching? A. <My elbows should be flexed 20-30 degrees, while walking.= <WBh. en I climb stairs I advance my affected leg first, with my crutches.= C. <I do not apply pressure under my arm when I use my crutches.= D. <When I am going to sit in a chair I put both crutches in the hand on my unaffected side.=
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client with a soft tissue injury. The client reports using a herbal remedy for 3 weeks prior to seeking health care but can not remember what was taken. The nurse should recognize that which of the following herbal remedies can be utilized effectively for soft tissue injuries? A. Saint John9s Wort B. Kava Kava C. Dong–Quai D. Aloe Vera
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client A. Scheduled for an EEG is washing the hair ortedBt.o have a magnetic resonance image (MRI) test and is attached to a C. Is being taught to hold the breath at intervals during a computerized tomography (CT Scan) D. On protective precautions is eating soup brought in by a visitor
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is reviewing laboratory data of the following clients. It would be a priority for the nurse to follow-up with the primary health care provider if a client with A. Coronary artery disease has a low density lipoprotein (LDL) level of 129mg/dl B. Primary hypertension has a sodium level of 144mEq/L C. Rhinosinusitis has a white blood count (WBC) of 11,500/ul DiabeDt. es mellitus type 1 has a glycosylated hemoglobin (hbA1c) level of 1
keep the door to the client’s room closed ACADEMICMA STER HESI RN EXIT EXAM 2021 A nurse is admitting a client with suspected pulmonary tuberculosis (TB). Which of the following actions should the nurse take? A. wear a gown and gloves when taking the client9s health history B. place the client on droplet precautions C. D. use sterile gloves when taking the client9s blood pressure
relieve the nurse of assigned clients ACADEMICMA STER HESI RN EXIT EXAM 2021 The charge nurse of a medical-surgical unit notices a nurse walking with an unsteady gait, slurred speech and a faint smell of alcohol on the breath immediately following a lunch break. The charge nurse9s priority action would be to A. notify the nursing supervisor B. asking the nurse about recent alcohol consumption C. complete an incident report D.
Call for additional help ACADEMICMA STER HESI RN EXIT EXAM 2021 The staff members of an out patient clinic have successfully assisted the clients to safety during a fire in the waiting area. Which action should the nurse perform next? A. Close all open doors B. C. Attempt to extinguish the fire D. Assess the clients9 vital signs
Contact the local reporting agency for suspected child abuse ACADEMICMA STER HESI RN EXIT EXAM 2021 While performing an assessment of a 3-year-old client, the nurse notices bruises in various stages of healing on the concealed surfaces of the body. Which action should the nurse take next? A. Document the locations of the bruises in the medical record B. Notify the primary health care provider C. D. Ask the parent to explain the injuries
Protect the patient from self-harm ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is developing a nursing care plan for a client who is the manic phase of bipolar disorder. Which intervention should the nurse include in the plan of care? A. B. Engage the client in competitive games C. Encourage the client to avoid foods that contain tyramine D. Place the client in an isolation room
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse on a psychiatric unit is caring for a client with paranoid schizophrenia who has lost 15 pounds within the past 3 weeks. The client accuses the staff of trying to poison all of the clients on the unit. Which of the following nursing interventions would be a priority for the nurse to include in the client’s plan of care? A. Determine the client9s favorite foods B. Offer the client small quantities of food at frequent intervals C. Sit with the client during meals DP.rovide the client with pre-packaged foods that the client likes
lanugo-type hair on body ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is admitting a 20-year-old client with anorexia nervosa. The nurse should assess the client for A. stained enamel of the teeth B. C. persistent ringing in the ears D. white patches on the tongue
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is admitting a client with major depression. It would be a priority for the nurse to A. Determine if the client was voluntarily admitted B. Ask the client if suicide has been contemplated C. Have the client9s possessions searched for sharps D. Administer to the client the prescribed antidepressant
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client with disseminated intravascular coagulation (DIC) who is receiving a unit of packed red cells. Thirty minutes after the start of the transfusion, the client reports chills and flank pain. The nurse should first A. Flush the intravenous tubing with normal saline B. Assess the client9s vital signs C. Stop the transfusion D. Notify the primary health care provider
B.Shave the operative area with a razor ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is preparing the pre-operative checklist for a patient. The nurse would need additional training if which of the following tasks were delegated to the UAP? A. Removing dentures, glasses, jewelry, and prosthesis C. Assist to void D. Obtain vital signs
metabolic alkalosis ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is reviewing a client’s ABG results, which reveal the following: pH 7.52, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3 32 mEq/L. The nurse should recognize that this result indicates which acid base imbalance? A. metabolic acidosis B. respiratory acidosis C. D. respiratory alkalosis
ACADEMICMA STER HESI RN EXIT EXAM 2021 A client with atrial fibrillation is receiving a continuous heparin infusion at 1000units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results? A. Prothrombin time (PT) of 12.5 seconds B. Activated partial thromboplastin time (PTT) of 60 seconds C. Activated partial thromboplastin (PT) time of 28 seconds D. Activated partial thromboplastin (PT) time longer than 120 seconds
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client who has been prescribed 1,000 ml of Ringer9s Lactate to infuse over 8 hours. The available intravenous set delivers 10 drops per milliliter. How many drops per minute should the nurse set the intravenous controller to administer? Answer
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse is caring for a client who has been prescribed 1,000 ml of Ringer9s Lactate to infuse over 8 hours. The available intravenous set delivers 10 drops per milliliter. How many drops per minute should the nurse set the intravenous controller to administer? Answer 21 gtts Vol X gtt factor 1000 mls X 10 gtts/ml time 8 hrs X 60 (480)
ACADEMICMA STER HESI RN EXIT EXAM 2021 The primary health care provider has prescribed an oral solution of Potassium Chloride (KCL) 20 mEq, po, daily. The drug available is Potassium Chloride 10 mEq/15 ml. How many mls should the nurse administer? Answer
ACADEMICMA STER HESI RN EXIT EXAM 2021 The primary health care provider has prescribed an oral solution of Potassium Chloride (KCL) 20 mEq, po, daily. The drug available is Potassium Chloride 10 mEq/15 ml. How many mls should the nurse administer? Answer _30 mls Ordered 20 mEq X On Hand 10 mEq 15ml 10 X = 300 X = 300/1030
ACADEMICMA STER HESI RN EXIT EXAM 2021 The nurse has a new prescription for Dopamine at 6mcg/kg/min. The patient weights 65kg. Dopamine concentration is 400mg/250ml. What rate should the nurse infuse the Dopamine via an infusion pump? ▶ Answer:
ACADEMICMA STER HESI RN EXIT EXAM 2021 ml 250ml 1mg 6mcg 65kg 60min hr = 400mg = 1000mcg = kg/min = 1min = 1 hr. = 5,850,000 = 14.6 400,000