HESI 2022

1. The Nurse is caring for a client admitted with a spontaneous pneumothorax. Which action should the nurse include in the client’s plan of care? a. Give bronchodilators by endotrac route b. Monitor bubbling of chest ...

1. The Nurse is caring for a client admitted with a spontaneous pneumothorax. Which action should the nurse include in the client’s plan of care? a. Give bronchodilators by endotrac route b. Monitor bubbling of chest unit until water-seal chamber c. Sch client for hyberbanic O2 therapy (HBOT) d. Administer antibiotics via long line IV cath 2. Following a cataract extraction and intraocular lens implantation, a client in the day surgery unit is reporting nausea. a. Position the cline to use an emesis basin b. Administer PRN antiemetic med IV c. Protect the operative eye from any risk for trauma d. Withhold diet progression until nausea subside 3. A group of nurses implement a pilot study to eval a proposed evidence based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which actions should be taken (SATA) a. Obtain informed consent from clients who rec care b. Arrange in-service training thru the Education Dept c. Submit a sentinel event report to the research committee d. Propose clinical prac guidelines to the nursing committee e. Invite data review by the QI Dep 4. A client is admitted with hypoparathyroidism. Which lab value indicates the nurse should place a client on a telemetry monitor? a. Calcium 6.5 mg/DL or 0.25 mmol/L b. Potassium 5.0 mEq/L or mmol/L c. Sodium 132 d. Magnesium 2.0 or 0.85 mmol/L 5. The RN is assessing a client with an AV fistula who has been rec hemodialysis for 2 years. The nurse auscultates a bruit over the site of the clients fistula. What action should the nurse take/ a. Contact the dialysis unit to r/x the next tx b. Document the finding in the EMR c. Elevate the affected arm on 2 pillows immediately d. Compare the BP readings in both arms 6. The nurse is completing the admission assessm. Of a 3 y/o who is admitted w/ bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased ICP/ a. BP fluctuations and syncope b. Tachycardia and tachypnea c. Increased head circumference and bulging fontanels d. Sluggish and unequal pupillary responses 7. The nurse is assisting the HCP 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? a. Chest tube insertion tray b. Ventilator c. Intubation Tray d. Crash Cart 8. When conducting diet teaching for a client who was dx with a MI, which snack foods should the nurse encourage the client to eat? (SATA) a. Fresh turkey slices and berries b. Raw unsalted almonds and apples c. Chicken bouillon soup and toast d. Fresh veggies with mayo dip e. Soda crackers and PB 9. The nurse is developing a plan of care for a client who reports intermittent claudication and who is newly dx w/ peripheral vas disease. Which outcome should the RN include in the plan of care for client? a. The nurse will show the client how to perform stress mgmt. tech b. The clients skin on the lower legs will be intact at the next clinical visit c. The nurse will monitor the clients skin condition for color changes d. The nurse will instruct clients fam about the prescribed diet 10. Which assessment finding of a postmenopausal woman necessitates a referral by the RN to a HCP for eval of thyroid functioning? a. Cold sesntivity b. Slow weight loss c. Muscle weakness d. Leg Numbness 11. The RN is planning to teach infant care and peventitive measures for SIDS to group of new parents. Which estimation is most important for the nurse to include? a. Ensure that the infants crib mattress is firm b. Swaddle the infant in a blanket for sleeping c. Prop the infant with a pillow when in a side lying positon d. Place the infant in prone position whenever possible 12. A client at 36 weeks gestation comes to the labor and delivery observation unit complaining of “leaking water”. Based on the client’s complaint, what action should the nurse take? a. Admit the client to labor and delivery if mucus if sound in the vagina vault. b. If nitrazine paper placed in the vaginal area turns blue, admit the client to labor and delivery c. Check the client’s blood pressure, and if it is within normal limits, allow her to go home d. Check the client’s complete blood count and notify the healthcare provider if the WBC is elevated 13. A client rec a Rx for 0.9% sodium chloride, USP 2 L IV to be infused over 24 hr. The IV administration set delivers 15gtt/ML. How many gtt/min should the RN regulate the infusion. (Numerical value, if rounding is required round to the nearest whole #) Answer: 21 14. An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as the result of cerebrovascular accident (CVA). which action should the nurse include in the plan of care? a. Teach the client to turn his head from side to side for visual scanning b. Provide additional light in the room to prom