ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022)

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.

275. An older adult female admitted to the intensive care unit (ICU) with a

possible stroke is intubated with a ventilator setting of tidal volume 600, PlO2 40%,

and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results

after intubation is PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To

normalize the client’s ABG finding, which action is required?

correct Answer- 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 experienced a loss of appetite. What instruction should

the nurse provide?

278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic

episodes and 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 Answer- 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

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/minute, respiratory rate 32

breaths/minutes, oxygen saturation 88%. Which interventions should the nurse

implement?

281. Before leaving the room of a confused client, the nurse notes that a half-bow

the 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?

282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis

media. Antipyrine and benzocaine-otic are also prescribed for pain and

inflammation. What instruction should the nurse emphasize concerning the

installation of the antipyrine/benzocaine otic solution?

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?

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)?

286. Following an outbreak of measles involving 5 students in an elementary

school, which action is most important for the school nurse to take? (correct

Answer- Restrict unvaccinated children from attending school until the 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?

289. When assessing a multigravida on 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?