HESI EXIT RN NAXLEX

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

catheters tubing

A client with a permanent pacemaker has no pulse or spontaneous respirations and the monitor is displaying a ventricular fibrillation rhythm. Resuscitation is in progress and the nurse is preparing to defibrillate the client with 200 joules of unsynchronized defibrillation. Which intervention is most important for the nurse to implement?

Place self-adhesive defibrillator pads at least 1 inch away from permanent pacemaker site.

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Establish a structured routine for the client to follow.

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

Present a personal perception of reality in a nonconfrontational manner.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include a heart rate of 122 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 170/90 mm Hg. Which assessment finding warrants the most immediate intervention by the nurse?

Bilateral diffuse wheezing.

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Cefazolin 1 gram IV every 6 hours.

A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. The vital signs are assessed as a temperature of 99.6° F (37.5° C), heart rate 98 beats/minute, respirations 28 breaths/minute, blood pressure 140/82 mm Hg, and a oxygen saturation 88% on room air.

Which action should the nurse implement?

Place the client in a forward-leaning position.

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Ineffective airway clearance.

The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?

Empty the bladder before and after sexual intercourse.

While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

Continue to obtain client data needed to complete the fall risk survey.

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

Take before bedtime.

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

Procure platelet products from the blood bank.

The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?

Nausea, vomiting, diaphoresis, anxiety, tremors.

The nurse is caring for a client who receives a prescription for parenteral lidocaine. Prior to administering the medication, the nurse should review the medical record for which condition?

Heart block.

Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?

Glucose and calcium levels.

To evaluate the effectiveness of a male client's new prescription for ezetimibe, which action should the clinic nurse implement?

Remind the client to keep his appointments to have his cholesterol level checked.

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Client's breath sounds are clear to auscultation bilaterally.

The nurse is reviewing nurses' notes to determine what the client's obstetric history reveals in the form of GTPAL.

Choose the most likely option for the information missing from the statement by selecting from the list of options provided. Based on the client's obstetrical history, the client's G-T-P-A-L designation is____________.

5-2-1-1-4

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity.

The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

An 82-year-old client with Alzheimer's disease and a newly fractured femur who has an indwelling urinary catheter and soft wrist restraints applied.

A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

Provide a bedside commode for toileting.

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

Bring a sterile chest drainage unit from central supply to the unit.

An older adult client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left sided paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care?

Facilitate a consultation for speech therapy.

A client is admitted with abdominal pain, loss of appetite, and a weight loss of 25 lb (11 kg) in the last four months. During the admission assessment, the client describes to the nurse of having no interest in playing cards with friends anymore and feels worthless most days. Which nursing problem should the nurse address first?

"Risk for self-directed violence as evidenced by feelings of hopelessness."

An older adult client is preparing for discharge following a myocardial infarction (MI). The nurse is reviewing the prescribed cardiac diet and exercise instructions with the client. Which action should the nurse implement while teaching?

Turn on overhead lights while giving instructions.

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

Simultaneous injections.

The nurse is caring for a client with chronic kidney disease (CKD). Which meal selection should the nurse recommend to the client?

Pasta with fish and an orange.

The nurse is providing teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management. Which response by the client indicates understanding?

Wear closed-toe shoes that are comfortable and fit well.

The nurse implements a tertiary prevention program for type 2 diabetes mellitus in a rural health clinic. Which outcome indicates that the program was effective?

Clients who developed disease complications promptly received rehabilitation.

A female client with aphasia is trying to verbalize feelings to the nurse and states, "I want...," but does not finish the statement. How should the nurse respond to this unfinished statement?

Allow the client time to complete her sentence.

A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

Give antispasmodic medications.

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?

Complete blood count.

A client who is admitted after an episode of status epilepticus is stabilized. Which finding should the nurse use to determine the client's risk for recurrence of seizure activity?

Therapeutic level of medication.

A client reports passing 2 to 3 small, hard stools per week since being placed on a low-residue diet three months ago. Which type of laxative should the nurse expect the healthcare provider to recommend first?

Bulk-forming.

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

Maintain the client on an NPO status.

A 18-year-old male client is admitted to the hospital with a possible drug overdose. His mother requests to know the results of the toxicology screen test. Which response is best for the nurse to provide?

"Only your son can decide to who the laboratory results can be shared with."

A parent brings their child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

Last dose and type of rescue inhaler used by the child.

An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gas results indicate hypoxia. Which intervention is most important for the nurse to implement?

Initiate comfort measures.

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

get annual flu and Pneumococcal vaccine polyvalent (PPSV23) vaccines.

The nurse is preparing an older adult client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

Avoid straining at stool, bending, or lifting heavy objects.

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

During acute illness.

The nurse is caring for a client who had surgery 1 day ago and is receiving a continuous infusion of fentanyl through an epidural catheter. Which intervention should the nurse perform first?

Monitor the client's dermatome level for sensation.

The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

Provide support of the spouse's feelings.

A father brings his preschool aged child to the clinic because of a sore throat for the past two days and currently has a temperature of 103° F (39.4°C). The child is pale around the mouth and has flushed cheeks. The nurse processes a positive rapid strep test as prescribed. Which information should the nurse provide to the child's parent? Select all that apply.

Sandpaper-like rash.

Peeling and flaking skin in a week.

The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

Chest tube insertion tray

A client undergoes an above-the-knee amputation (AKA) of the right leg because of peripheral vascular disease. On the second postoperative day, the nurse enters the room to take the client's vital signs and finds the client lying in a prone position. The client asks for assistance in turning. Which action should the nurse take first?

Determine how long the client has been lying prone

After being treated in the emergency department for an opioid overdose two weeks ago, a client arrives to an outpatient treatment clinic. During the admission interview with the nurse, the client denies having a problem with opioid addiction, but admits to gradually increasing the dosage. Which approach is best for the nurse to make

Explore other coping strategies aside from using medications.

A client with cirrhosis of the liver is having numerous, liquid, incontinent stools, and continues to be confused. In reviewing the client's laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for this client to receive?

Lactulose.

A client's most recent vital signs include heart rate 80 beats/minute and blood pressure 119/70 mm Hg. When the client reports dizziness after rising quickly, which finding should the nurse expect on reassessment?

Heart rate 100 beats/minute.

Which oral medication can the nurse safely cut in half?

The tablet in option C has a scored line (a groove down the middle), which indicates that it can be safely split. Scored tablets are manufactured to ensure even distribution of the active ingredient, making it safe for dose division.

A woman and her live-in significant other come in the emergency department following a motor vehicle collision. Which finding should alert the nurse to assess for the possibility of domestic violence?

spiral fracture on the woman's arm and wrist.

The nurse is teaching a client's family member about seizure precautions. Which action described by the family member indicates the need for additional teaching?

Secure the limbs to the body.

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

Move the client to a quiet place on the unit.

When should intimate partner violence (IPV) screening occur?

As a routine part of each health care encounter.

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Evaluate the newly hired UAP's level of competency by observing the UAP deliver care.

The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

Take prescribed cortisone accurately.

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Nurse case manager.

A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis. The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements. Which factor is the most likely cause for this problem?

Pain when eating.

A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Rhythm of apical pulse.

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

Expect a persistent cough after the procedure.

After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient. During a follow-up visit at the community clinic, the nurse observes that the client has developed jaundice. Which action should the nurse take?

Explain the need to evaluate liver function.

A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client reports pain at the right groin insertion site. Which action should the nurse implement?

Check femoral site for hematoma formation.

A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history includes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?

Avoid the consumption of wine, beer, and coffee.

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

Right foot is cool to the touch and appears pale and blanched.

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Deed area of persistent redness over bone.

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

Notify information services department of the situation.

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

Plain baked sweet potato.

An adult client was diagnosed with stage IV lung cancer three weeks ago. The client's spouse approaches the nurse and asks how to know that the spouse's death is imminent because their two adult children want to be there when the client dies. Which is the best response by the nurse?

Explain the client will start to lose consciousness and the body systems will slow down.

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

An older client who is one day postoperative with a colostomy for colon cancer.

An older adult client who fell at the store is admitted with a possible fracture of the right hip. Which assessment finding should the nurse report to the healthcare provider?

Right leg externally rotated and shorter than left.

The nurse is admitting a client from the post-anesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first?

Straight catheterization if unable to void.

he nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child?

Make certain the child is maintained in correct body alignment

A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?

"Would you please clarify what you have written so I am sure I am reading it correctly?"

The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?

Cough and deep breathe every 2 hours

Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)?

Avoid direct sunlight

A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should

Administer the prescribed analgesia

The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse?

"The seizure may or may not mean your child has epilepsy."

A woman who delivered 5 days ago and had been diagnosed with preeclampsia calls the hospital triage nurse hotline to ask for advice. She states " I have had the worst headache for the past 2 days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next?

advise the client to have someone bring her to the emergency room as soon as possible

For which of the following mother-baby pairs should the nurse review the Coomb's test in preparation for administering RhO (D) immune globulin within 72 hours of birth?

Rh negative mother with Rh positive baby

A female client with breast cancer is scheduled to receive a series of radiotherapy (RT). She has red hair, fair skin, and freckles. She tells the nurse that her skin is particularly sensitive to the sun, so she is worried that the radiation will adversely affect her skin. Which information should the nurse provide this client about RT? Select all that apply.

Both the sun and radiation can damage the skin because it has a rapid renewal rate.

Shielding helps to localize the entrance of RT and protects other sensitive areas.

Special gels can be prescribed for local application to promote healing and comfort.

The nurse is preparing to administer enoxaparin 30 mg subcutaneously using a pre-filled syringe containing 30 mg in 0.3 mL. Which action should the nurse implement?

Retain the air bubble in the syringe barrel.

A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Ventricular arrhythmias.

The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care?

Falls.

A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?

Assessment of a bruit on the left forearm.

An older adult client is having photocoagulation for macular degeneration. Which intervention should the nurse implement during the postprocedure care in the outpatient surgical unit?

Verbally identify self when entering the room

A female client with degenerative disc disease and chronic sciatica is describing numbness and tingling down her left leg. Which assessment should the nurse obtain first?

Duration of sensation.

When providing education for a client newly diagnosed with type 1diabetes, which information is most important for the nurse to provide the client?

Teach how to recognize and treat hypoglycemia.

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

Upper body muscle strength.

A client who has type 2 diabetes mellitus is admitted to the intensive care unit with third degree burns over 20% of the body. To decrease the client's risk of developing hyperosmolar hyperglycemic syndrome (HHS), which intervention(s) should the nurse implement? Select all that apply.

Titrate an insulin infusion to maintain a low serum glucose level.

Monitor serum electrolyte levels and report any abnormal values.

Maintain large bore IV patency for aggressive fluid resuscitation.

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use when developing the client's plan of care?

Confusion.

A client diagnosed with Parkinson's disease receives a prescription for carbidopa-levodopa, controlled release (CR) 25/100 mg PO daily each morning. Which information should the nurse include in the client's teaching plan? Select all that apply.

An upset stomach may occur as a side effect of this medication.

A change in urine color to dark red often occurs while taking this drug.

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal?

Vitamin supplements for high-risk pregnant women.

The nurse is caring for a client with left-sided hemiparesis after a stroke. Which action should the nurse take to safely assist the client with ambulation?

Use a gait belt standing on affected side.

After diagnosis and initial treatment of a pre-school age child with cystic fibrosis, the nurse provides home care instructions to the parents. Which statement by the child's parents indicates that understanding of the home care treatment to promote pulmonary function?

"Chest physiotherapy should be performed twice a day before a meal."

The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)?

Measure the client's body weight each morning.

The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?

Ask the client to describe the pain.

A client who has asthma receives a new prescription for a corticosteroid inhaler. The client expresses concern about taking steroid medications. Which information should the nurse provide the client about the use of this maintenance inhaler?

Systemic side effects are reduced when taken by inhalation.

In caring for a client with chronic kidney disease (CKD), the nurse notes that the client's serum phosphate level is elevated, with a converse decrease in serum calcium. Which nursing care goal is a priority, based on these laboratory findings?

Prevent injury.

A client with eczema is experiencing severe pruritus. Which PRN prescription(s) should the nurse administer? Select all that apply.

Topical corticosteroid.

Oral antihistamine.