Fundamental 1 1st Hesi Exit Exam Bsn

2Thenursehascompletedthedietteachingofaclientwhoisbeingdischargedfollowingtreatmentofalegwound.Ahighproteindietisencouragedtopromotewoundhealing.Whichlunchchoicebytheclientindicatesthattheteachingwaseffective?a. Apeanutbuttersandwichwithsodaandcookies.b. Atunafishsandwichwithchipsandicecream.c. Vegetablesoup,crackers,andmilk.d. Asaladwiththreekindsoflettuceandfruit.3Thenurseimplementsaprimarypreventionprogramforsexuallytransmitteddiseasesinanursemanagedhealthcenter.Whichoutcomeindicatesthattheprogramwaseffective?A. Averageclientscoresimprovedonspecificriskfactorknowledgetest.B. Morethanhalfofat-riskclientwerediagnosedearlyintheirprocess.C. Newscreeningprotocolsweredeveloped,validated,andimplemented.D. Clientswhoincurreddiseasecomplicationspromptlyreceivedrehabilitation.4Ayoungadultclientisadmittedtotheemergencyroomfollowingamotorvehiclecollision.Theclient'sheadhitthedashboard.Admissionassessmentsincludebloodpressure85/45mmHg,oraltemperature98.6F(37C),pulse124beats/minute,andrespirations22breaths/minute.Basedonthesedata,thenurseformulatesthefirstportionofanursingproblemas"Riskforinjury".Whattermbestexpressesthe"relatedto"portionofthenursingproblem?a. headinjury.b. infection.c. increasedintracranialpressure.d. shock.5Anurseworkingonanendocrineunitshouldseewhichclientfirst.a. Anadolescentmalewithdiabeteswhoisarguingabouthisinsulindose.b. AnolderclientwithAddisonsdiseasewhosecurrentbloodsugarlevelis62mg/dl(3.44mmol/l).c. Anadultwithabloodsugarof384mg/dl(21.31mmol/l)andurineoutputof350mlinthelasthour.d. Aclienttakingcorticosteroidswhohasbecomedisorientedinthelasttwohours.6Followingagunshotwound,anadultclienthasahemoglobinlevelof4grams/dl(40mmol/LSI).Thenursepreparestoadministeraunitofbloodforanemergencytransfusion.TheclienthasABnegativebloodtypeandthebloodbanksendsaunitofTypeARhnegative,reportingthatthereisnoTypeABnegativebloodcurrentlyavailable.Whichinterventionshouldthenurseimplement?a. TransfuseTypeAnegativeblooduntilTypeABnegativeisavailable.b. Rechecktheclienfshemoglobin,bloodtype,andRhfactor.c. ObtainadditionalconsentforadministrationofTypeAnegativeblood.d. AdministernormalsalinesolutionuntilTypeABnegativeisavailable.7Anolderclientwholivesaloneinatwo-storyhomeisadmittedafterfallingwhileshopping.X-raysrevealafracturedlefthip.Withnoimmediatefamilyinthearea,theclientisconcernedaboutthepetsathome.Whichinterventionsshouldthenurseimplement?(Selectauthatapply.)A-EvaluatepainusingastandardpainscaleB-Alertsocialworkerofclient'sconcerns.C-Supportleftlegwithtwopillows.D-Palpateandmarkpedalpulses.E-Assessabilitytobearweightwhenstanding8Whichlaboratoryfindingforanadultclientismostcriticalforthenursetoreporttothehealthcareprovider?(Clickonthecorrectlocationonthechart.Tochange,clickonanewlocation.) SerumSodio142mEq/L(142mmol/L) Postassium3.9mEq/L(3.9mmol'/L) Serumglucose62mg/dl(3.4mmdl/L) Bloodureanitrogen18mg/dl(6.4mmol/L)O9Anolderadultclientwithheartfailure(HF)developscardiactamponade.Theclienthasmuffled,distant,heartsounds,andisanxiousandrestless.AfterinitiatingoxygentherapyandIVhydration,whichinterventionismostimportantforthenursetoimplement?a. Observeneckforjugularveindistentionb. Notifyhealthcareprovidertoprepareforpericardiocentesisc. Assesforparadoxicalbloodpressured. Monitoroxygensaturation(Sp02)viacontinuouspulseoximetry10Theparentofachildbornwithacleftlipasksthenursetoexplainwhythishappened.Theparentisconcernedthattheydidsomethingwrongthatcausedthistooccur.Whichresponseismosthelpful?a. "Youdidn'tdoanythingwrong."b. "Thismustbeaverydifficulttimeforyou."c. "Withsurgery,yourbabyshouldhaveafullrecovery.d. "Isthereanyparticularreasonwhyyouthinkthisisyourfault?11Afterdiagnosisandinitialtreatmentofa3-year-oldwithCysticfibrosis,thenurseprovideshomecareinstructionstothemother,whichstatementbythechild'smotherindicatesthatsheunderstandshomecaretreatmenttopromotepulmonaryfunctions?a. Chestphysiotherapyshouldbeperformedtwiceadaybeforeameal.b. Administeracoughsuppressantevery8hours."c. Energyshouldbeconservedbyschedulingminimallystrenuousactivities."d. Maintainsupplementaloxygenat4to6Uminute."12Aclientwithdeepveinthrombosis(DVT)isreceivingacontinuousintravenousheparininfusion.Theclientnowhastarry,blackdiarrheaandreportsabdominalpain.Whichactionsshouldthenurseimplement?(Selectallthatapply.)a. Auscultatebowelsoundsinallquadrants.b. Reviewlastpartialthromboplastintimeresults.c. Assesscharacteristicsofpain.d. Preparetoadministerwarfarin.e. Monitorstoolsforpresenceofblood.13Thenurseisdevelopingateachingprogramforthecommunity.Whatpopulationcharacteristicismostinfluentialwhenchoosingstrategiesforimplementingateachingplan?a. Literacylevel.b. Medianage.c. Prevalentlearningstyle.d. PercentwithInternetaccess.14Thenurseisconductingavisualscreeningofagroupofolderadults.Whichfindingshouldthenursereporttothehealthcareproviderimmediately?a. Gradualonsetofcontinuouseyepainandblurredvision.b. Recentchangeintheabilitytoreadanddriveafterdark.c. Gray-whitecirclearoundtheirisofbotheyes.d. Cloudyopacityofthecrystallinelens.15Whilethenurseisassessinganolderclient'sfallrisk,theclientreportslivingathomealoneandneverfalling.Whichactionshouldthenursetake?a. Informtheclientthatfallsoccurmoreofteninthehospitalthanathome.b. Continuetoobtainclientdataneededtocompletethefallrisksurvey.c. Recordaminimalriskforfalls,documentingtheclient'sstatement.d. Placetheclientonahighfallriskprotocolbecauseofadvancedage.16Aclientwithgestationaldiabetesisbeinginducedforlabor.Whichassessmentismostimportantforthenursetoperformpriortoincreasingtheoxytocinrate?a. Contractionpattern.b. Bloodpressure.c. Fingerstickglucose.d. Vaginalexam.O17Aclientisreceivingcontinuousambulatoryperitonealdialysissincethearteriovenous(AV)graftintherightarmisnolongeravailabletouseforhemodialysis.Theclienthaslostweight,hasincreasingperipheraledema,andhasaserumalbuminlevelof1.5g/dl(15g/L).Whichinterventionisthepriorityforthenursetoimplement?a. Ensuretheclientreceivesfrequentsmallmealscontainingcompleteproteins.b. Recommendtheuseofsupportstockingstoenhancevenousreturn.c. EvaluatepatencyoftheAVgraftforresumptionofhemodialysis.d. Instructtheclienttocontinuetofollowtheprescribedrigidfluidrestrictionamounts.18Followingamotorvehiclecollision(MVC),anunrestrainedclientisadmittedtotheintensivecareunitwithalteredmentalstatus.Theclienthasmultipleribfracturesandbruisingacrossthelowerabdomen.Whichassessmentfindingwarrantsimmediateinterventionbythenurse?(Pleasescrollandvieweachtab'sinformationintheclient'smedicalrecordbeforeselectingtheanswer.)a. Alargeamountofgrosshematuria.b. Severalapneaepisodeslastingtenseconds.c. Delayedperipheralcapillaryrefill.d. Numbnessoftheleftlowerextremity.19Whichclientrequirescarefulnursingassessmentforsignsandsymptomsofhypermagnesemia?a. Aclientwhodevelopedhyperparathyroidisminlateadolescence.b. Afemaleclientwhoisoverzealouswithherintakeofsimplecarbohydrates.c. Amiddle-agedmaleclientinrenalfailurefollowinganunsuccessfulkidneytransplant.d. Ayoungadultclientwithintractablevomitingfromfoodpoisoning.20Anunlicensedassistivepersonnel(UAP)leavestheunitwithoutnotifyingthestaff.InwhatordershouldtheunitmanagerimplementtheseinterventionstoaddresstheUAP'sbehavior?(Placetheactionsinorderfromfirstontoptolastonbottom.)a. Notedateandtimeofthebehaviorb. DiscusstheissueprivatelywiththeUAP.R/NDPEc. EvaluatetheUAPforsignsofimprovement.d. Planforscheduledbreaktimes.21Thenurseispreparinganoldermaleadultfordischargewhodoesnotreadandhasbilateralhearingloss.Theclient'sdaughterwholivesclosetoherfathertellsthenursethatshewillstopbydailytocheckonherfather.Whichinterventionsshouldthenurseimplement?(Selectallthatapply.)a. Includethefamilyinthedischargeteaching.b. Faceclientwhenspeaking.c. Encouragetheclienttoattendreadingclasses.d. Speakloudlywhenteaching.e. Providethedaughterwithwritteninstructions.22Aclientwithdelusionstellsthenurse,"Youaren'tdoingyourjob.Gogetthosepeopleoverthereandshootthembeforetheygetme."Whichstatementisthenurse'sbestresponse?a. "Youareinasafeplace.Noonecangettoyouhere.b. "Thereisnoonewhowillhurtyou."c. "Whatwouldyouliketoseemedotoprotectyou?d. "Youseemquitefrightenedrightnow.23Thenurseiscaringforanadolescentwhofell20feet(6.1meters)5monthsagowhileclimbingthesideofacliffandhasbeeninasustainedvegetativestatesincetheaccident.Whichinterventionshouldthenurseimplement?a. Inquireaboutfoodallergiesandfoodlikesanddislikes.b. Talkdirectlytotheadolescentwhileprovidingcare.c. Monitorvitalsignsandneurostatusevery2hours.d. Initiateopencommunicationwiththeteensparents.24Inpreparingadiabeteseducationprogram,whichgoalshouldthenurseidentifyastheprimaryemphasisforaclassondiabetesself-management?a. Preparetheclienttoindependentlytreattheirdiseaseprocessb. Reducehealthcarecostsrelatedtodiabeticcomplicationsc. Enableclientstobecomeactiveparticipatingincontrollingthediseaseprocessd. Increaseclientsknowledgeofthediabeticdiseaseprocessandtreatmentoptions.25Aclientwithalowerrespiratorytractinfectionreceivesaprescriptionforciprofloxacin500mgPOq12hours.Whentheclientrequestsanafternoonsnack,whichdietarychoiceshouldthenurseprovide?a. Vanilla-flavoredyogurtb. Lowfatchocolatemilk.c. Calciumfortifiedjuiced. Cinnamonapplesauce26Duringapostpartumassessmentofaclientwhois5hourspostvaginaldelivery,thenursedeterminesthefundusis3fingerbreadthsabovetheumbilicusandpositionedtotheclient'sleftside.Whichactionshouldthenurseimplementfirst?a. Encouragetheclienttovoid.b. Provideadditionaloralreplacementfluids.c. Massagethefundusuntilfirm.d. Catheterizeforresidualurinaryvolume.27Amaleclientwithmultiplemyelomaisadmittedwithpneumoniaandpancytopenia.Thenursereviewsthecompletebloodcellcountfindingsandidentifiesaplateletcountof20,000cells/mm.Whichinterventionshouldthenurseincludeintheclientsplanofcare?A. Monitorintakeandoutput.B. Paceactivitiesbetweenplannedrestperiods.C. Avoidintramuscularinjections.D. Limitsexposuretovisitorswithrespiratoryinfections.28Whenassessingaclient,thenurseshouldestablishwhichfindingsasobjective?(Selectallthatapply.)a. Diaphoresis.b. Edema.c. Nausea.d. Urticaria.e. Hypertension.f. Anxiety.29Thenurseassistsaclientwhohasobstructivesleepapnea(OSA)witheveningcare.Whichinterventionismostimportantforthenursetoimplementbeforeleavingtheclientalone?a. Elevatetheheadofthebedtoa45-degreeangle.b. Removedenturesorotheroralappliance.c. Liftandlockthesiderailsinplace.d. Applytheclient'spositiveairwaypressuredevice.30Thenurseadministersanantibiotictoaclientwitharespiratorytractinfection.Toevaluatethemedication'seffectiveness,whichlaboratoryvaluesshouldthenursemonitor?(Selectallthatapply.)a. Sputumcultureandsensitivity.b. Serumpotassium.c. Redbloodcell(RSC)count.d. Bloodureanitrogen(BUN).e. Urinalysis.f. Whitebloodcell(WBC)count.31Aclientarrivesattheemergencydepartment(ED)describingchestpainthatbeganthreehoursearlierwhichhasnotsubsided.Toassessthequalityoftheclient'schestpain,whichapproachshouldthenurseuse?a. Asktheclienttodescribethepain.b. Provideanumericpainscale.c. Observebodylanguageandmovement.d. Identifyeffectivepainreliefmeasures.32Thenurseisassessinga3-month-oldinfantwhohadapylorotomyyesterday.Thischildshouldbemedicatedforpainbasedonwhichfindings?(Selectallthatapply.)a. Increasedtemperature.b. Increasedpulserate.c. Peripheralpalloroftheskin.d. Restlessness.e. Increasedrespiratoryrate.f. Clenchedfists.33Aclientwithaprescriptionfordonotresuscitate(DNR)beginstomanifestsignsofimpendingdeath.Afternotifyingthefamilyoftheclientsstatus,whatpriorityactionshouldthenurseimplement?A. Theimpendingsignsofdeathshouldbedocumented.B. Thenursemanagershouldbeupdateontheclientsstatus.C. Theclientstatusshouldbeconveyedtothechaplain.D. Theclientsneedforpainmedicationshouldbedetermine.34Anadultsufferedburnstofaceandchestresultingfromagreasefire.Onadmission,theclientwasintubated,anda2-literbolusofnormalsalinewasadministeredIV.Currentlythenormalsalineisinfusingat250ml/hour.Theclient'sheartrateis120beats/minute,bloodpressureis90/50mmHg,respirationsare12breaths/minuteovertheventilated12breathsforatotalof24breaths/minute,andthecentralvenouspressure(CVP)is4mmH20.Whichinterventionshouldthenurseimplement?a. Infuseanadditionalbolusofnormalsaline.b. Increasetheoxygendeliveredbytheventilator.c. Lowerheadofthebedtoarecumbentposition.d. Bringatracheotomytraytothebedside.35Thenursediscoversthatamaleclienthasattemptedsuicidebyslashinghiswrists.Whatshouldthenursedofirst?a. Estimatetheamountofbloodloss.b. Determinethedepthoftheslashes.c. Checktheclient'slevelofconsciousness.d. Findtheobjectusedtocausetheinjuries.36Aclientwasadmitted36hoursagoforaheadinjurythatoccurredastheresultofamotorcycleaccident.Inthelast4hours,theclient'surineoutputhasincreasedtoover200ml/hour.Beforereportingthefindingtothehealthcareprovider,whichinterventionshouldthenurseimplement?a. Measureoralsecretionssuctionedduringlast4hours.b. Obtaincapillarybloodsamplesforglucoseevery2hours.c. Obtainbloodpressureandassessfordependentedema.d. Evaluatetheurineosmolalityandtheserumosmolalityvalues.37InformulatingthenursingcareplanforaclientdiagnosedwithParkinson'sdisease,whichnursingproblemhasthehighestpriority?0a. Riskforaspirationrelativetomuscleweakness.b. Riskforconstipationrelativetoimmobility.c. Self-caredeficitrelativetomotordisturbance.d. Impairedphysicalmobilityrelativetomusclerigidity.38Amaleclientwhoisparticipatinginanangermanagementassignmentasksifhecanmakealeatherbeltinoccupationaltherapy.Theclientbeginspoundingtheleathervigorouslywithamallettoimprintdesignsonthebelt.Whichdefensemechanismistheclientusing?A. Regression.B. Compensation.C. Sublimation.D. Suppression.39A6-month-oldinfantisadmittedtothehospitalwithdiarrhea.Themotherisfeedingtheinfantabottleoftapwaterandtellsthenursethatthebabyhastakenthree8-ouncebottlesofwaterinthelast4hours.Whichlaboratoryfindingismostimportantforthenursetomonitor?A. Serumsodiumlevels.B. Whitebloodcellcount.C. Creatinineclearance.D. Serumpotassiumlevels.40Amotherbringsher2-month-oldinfanttotheclinicforawell-babyappointment.Thenurseobtainsahistoryandconductsphysicalassessment.Whichfindingrequiresthemostimmediateintervention?A. Bilateralretinalhemorrhages.B. Motherdescribesinfantasirritable.C. ApositiveOrtolanimaneuver.D. Historyofpoorfeedingandvomiting.41Thechargenurseisplanningfortheshiftandhasaregisterednurse(RN)andapracticalnurse(PN)ontheteam.WhichclientshouldthechargenurseassigntotheRN?a. A75-year-oldclientwithrenalcalculiwhorequiresurinestraining.b. A64-year-oldclientwhohadatotalhipreplacementthepreviousday.c. Anadolescentwithmultiplecontusionsduetoafallthatoccurred2daysago.d. A30-year-olddepressedclientwhoadmitstosuicideideation.42Oneweekafteranabove-the-kneeamputation(AKA)oftheleftleg,amaleclientseemsupsetandreportsthathisleftfootfeels"numb."Whatactionshouldthenurseimplement?"a. Assessrightfootforsignsofdiminishedcirculation.b. Offerassurancethatthenumbfeelingistemporary.c. Reinforcelearningaboutthecauseofthissensation.d. Assesswoundforsignsofinflammationordrainage.43A16-year-oldmaleclientwhohasbeentreatedinthepastforaseizuredisorderisadmittedtothehospital.Immediatelyafteradmissionhebeginstohaveagrandmalseizure.Whichactionshouldthenurseimplement?a. Calltherapidresponseteam.b. Placeapaddedtonguebladebetweenclient'steeth.c. Observetheclientcarefully.d. Obtainassistanceinholdinghimtopreventinjury.44ThenurseisdevelopingtheplanofcareforaclientwithpneumoniaandincludesthenursingdiagnosisofIneffectiveairwayclearancerelatedtothickpulmonarysecretions.Whichinterventionismostimportantforthenursetoincludeintheclientsplanofcare?a. Increasefluidintaketo3,000ml/dailyb. Maintaintheclientinasemi-Fowler'sposition.c. Administer02at5Minutespernasalcannula.d. Providefrequentrestperiods.45Twoweekspost-burn,amaleclientwith40%deeppartial-thicknessinjurycontinuestohaveopenwoundsandisnowdevelopingdiarrhea.Hisbloodpressureis80/40mmHgandhistemperatureis96F(35.6C).Whichactionismostimportantforthenursetotake?A. Increasedtheroomtemperature.B. Assesstheoxygensaturation.C. Notifytherapidresponseteam.D. Continuetomonitorvitalsings.46Thenurseisdevelopinganeducationalprogramforolderclientswhoarebeingdischargedwithnewantihypertensivemedications.Thenurseshouldensurethattheeducationalmaterialsincludewhichcharacteristics?Selectallthatapplya. Writtenatatwelfth-gradereadinglevelb. Printedusinga12-pointtypefontc. Containsalistwithdefinitionsofunfamiliartermsd. UsescommonwordswithfewSyllablese. Usespicturestohelpillustratecomplexideas47Aclientwithgeneralizeanxietydisorderdoesnotwanttocommunicatewithfriends,smokes2to3packagesofcigarettesaday,anddescribedifficultyconcentratingatwork.Whichcopingstrategyshouldthenurseincludeintheplanofcare?A. Analyzepasthurtsandresentmentstoidentifythesource.B. Concentrateonandventilateemotionswhendistressed.C. Relaxandreducetheamountofefforttosolvetheproblem.D. Focusonsmallachievabletasks,nottaxingproblems.48Aclientwhohasarightsubclavianveincentralvenous(CV)cathetertransducingcontinuouscentralvenouspressures(CVP)reportsthereturnofmidsternalchestpressure.TheclientreceivesprescriptionsforaSTAT12-leadelectrocardiogramandtroponinlevel.WhilethenursewithdrawsbloodfromtheCVcatheter,thebedsidemonitorbeginstoalarm.Whichfactorshouldnursefirstsuspectiscausingthemonitortoalarm?a. BloodintheCVline.b. Lethalcardiacrhythm.c. AirintheCVline.d. LossofCVPwaveform.49Aclientwithadvancedcirrhosisisbeingtreatedforhepaticencephalopathy.Inreviewingtheclient'sserumlaboratoryresults,whichfindingrequiresthemostimmediateinterventionbythenurse?a. Loweredtotalproteinandalbumin.b. Elevateddirectbilirubin.c. Decreasedammonia.d. Prolongedprothrombintime(PT).50Whichassessmentfindingismostimportantwhenplanningtoprovideacompletebedbathtoabedfastclient?a. Pallor.b. Orthopnea.c.