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Hesi Exit Exam | A++++++Questions and Answers | Latest 2023/2024 1. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10 mEq/5ml." how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.) ~ Answer: 12.5  Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml= 12.5ml 2. At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? ~ Answer: Place a wedge under the client's right hip.  Rationale: Hypotension from pressure on the vena cava is a risk for the full-term client. Placing a wedge under the right hip will relieve pressure on the vena cava. Other options will either not relieve pressure on the vena cava or would not allow the client the remaining her position of choice. 3. A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? ~ Answer: Titrate the dopamine infusion to raise the BP.  Rationale: the client is experiencing cardiogenic shock and requires titration per protocol of the vasoactive secondary infusion, dopamine, to increase the blood pressure. Low hourly urine output is due to shock and does not indicate a need for catheter irrigation. Pacing is not indicated based on the client's capillary blood glucose should be monitored, but is not directly indicated at this time. 4. The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam? ~ Answer: Evaluate the client's mood, cognition and orientation.  Rationale: the mental status exam assesses the client for abnormalities in cognitive functioning; potential thought processes, mood and reasoning, the other options listed are all components of the client's psychosocial assessment. 5. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) ~ Answer: Administer a daily dose of lisinopril as scheduled. ~ Provide a PRN dose of acetaminophen for headache.  Rationale: the client' routinely scheduled medication, lisinopril, is an antihypertensive medication and should be administered as scheduled to maintain the client's blood pressure. A PRN dose of acetaminophen should be given for the client's headache. The other options are not indicated for this situation. 6. When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply) ~ Answer: Pasta, noodles, rice. ~ Egg, tofu, ground meat. ~ Mashed, potatoes, pudding, milk.  Rationale: a client's postoperative diet is commonly progressed as tolerated. A soft diet includes foods that are mechanically soft in texture (pasta, egg, ground meat, potatoes, and pudding. High fiber foods that require thorough chewing and gas forming foods, such as cruciferous vegetables and fresh fruits with skin, grains and seeds are omitted. 7. The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? ~ Answer: Reposition the infant every 2 hours.  Rationale: An infant, who is receiving phototherapy for hyperbilirubinemia, should be repositioned every two hours. The position changes ensure that the phototherapy lights reach all of the body surface areas. Bathing, feedings, and diaper changes are ways for the parents to bond with the infant, and can occur away from the treatment. Feedings need to occur more frequently than every 4 hours to prevent dehydration. The infant should wear only a diaper so that the skin is exposed to the phototherapy 8. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? ~ Answer: Withhold food and fluid intake.  Rationale: The pathophysiologic processes in acute pancreatitis result from oral fluid and ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. The main focus of the nursing care is reducing pain caused by pancreatic destruction through interventions that decrease GI activity, such as keeping the client NPO. Other choices are also important intervention but are secondary to pain management. 9. Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipation. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply) ~ Answer: Include oatmeal with stewed pruned for breakfast as often as possible. ~ Increase fluid intake by keeping water glass next to recliner. ~ Recommend seeking help with regular shopping and meal preparation.  Rationale: older adult are at higher risk for chronic constipation due to decreased gastrointestinal muscle tone leading to reduce motility. Oatmeal with prunes increases dietary fiber and bowel stimulation, thereby decreasing need for laxatives. Increased fluid intake also decreases constipations. Assistance with food preparation might help the client eat more fresh fruits and vegetables and result on less reliance on microwaved and fast foods, which are usually high in sodium and fat with little fiber. Laxatives can be reduced gradually by improving the diet, without resorting to using enemas. 10. A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next? ~ Answer: Determine the mother's basic skill level in providing care.  Rationale: Although the mother states she is a capable caregiver, the client is manifesting disuse syndrome complications, and the mother's skill in providing basic care should be determined. Further assessment is needed before implementing other nursing actions. 11. After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart heating during the procedure. What action should the nurse take? ~ Answer: Notify the healthcare provider of the client's lack of understanding.  Rationale: the nurse is only witnessing the signature, and is not responsible for the client's understanding of the procedure. The healthcare provider needs to clarify any questions and misconceptions. Explaining the procedure again is the healthcare provider's legal responsibility. The other options are not indicated.