HESI Exit Exam Key Topics Review

Here are 100 questions that would help you prepare for your HESI exit exam. A client taking digoxin has a serum potassium level of 3. What intervention should a nurse prioritize? A. Administer a potassium supplement. B. Withhold the digoxin. C. Increase the digoxin dose. Or D. Encourage a diet high in sodium. The answer is B. Withhold the digoxin. Hypokalemia increases the risk of digoxin toxicity. Withholding the digoxin and addressing the low potassium level is the priority to prevent adverse effects. A client post-thyroidectomy develops tingling around the mouth and fingers. What action should a nurse take first? A. Administer calcium gluconate. B. Increase the IV fluid rate. C. Notify the healthcare provider or D. Document the finding. The answer is A. Administer calcium gluconate. Tingling around the mouth and fingers may indicate hypocalcemia, a potential complication post-thyroidectomy. Administering calcium gluconate is a rapid intervention to address low calcium levels. A client with major depressive disorder is started on Sertraline. The nurse provides education about the medication, emphasizing the need to A. Take the medication with food B. Abruptly stop the medication if side effects occur C. Expect immediate improvement in mood or D. Avoid concurrent use of other antidepressants. The answer is D. Avoid concurrent use of other antidepressants. Concurrent use of multiple antidepressants can lead to serotonin syndrome. Educating the client about potential interactions and the importance of avoiding other antidepressants is crucial. A pregnant client is diagnosed with preeclampsia. What assessment finding is indicative of severe preeclampsia? A. proteinuria, B. Blood pressure of 140 over 90, C. Presence of ankle edemia, or D. Epigastric pain. The answer is D. Epigastric pain. Epigastric pain is a sign of severe preeclampsia and may indicate liver involvement. It requires prompt intervention and close monitoring. The nurse is assessing a toddler with suspected dehydration. What finding is indicative of moderate dehydration? A. Capillary refill less than two seconds. B. Sunken fontanels. C. Increased urine output or D. Weight gain. The answer is B. Sunken fontanels. Sunken fontanels are a sign of moderate dehydration in a toddler. It indicates decreased fluid volume and warrants further assessment and intervention. A client receiving heparin therapy reports unusual bleeding, including nosebleeds and blood in the urine. What action should a nurse take? A. Administer vitamin K. B. Monitor platelet count. C. Increase the heparin dose. D. Administer protamine sulfate. The answer is B. Monitor platelet count. Unusual bleeding may indicate heparin-induced thrombocytopenia, or HIT. Monitoring the platelet count is essential to assess for this potentially serious complication. A client with chronic obstructive pulmonary disease is prescribed oxygen therapy. What should a nurse monitor for as a potential side effect of oxygen therapy? Increased respiratory rate, elevated blood pressure, decreased level of consciousness, or dry mucous membranes? The answer is A, increased respiratory rate. Oxygen therapy can suppress the hypoxic drive in clients with COPD, leading to a decreased respiratory rate. Monitoring for respiratory changes is therefore essential. A client with type 1 diabetes reports feeling shaky, sweaty, and anxious. What interventions should a nurse implement? Administer glucagon, provide a snack high in protein, administer regular insulin, or increase the frequency of insulin injections. The answer is B, provide a snack high in protein. The client is likely experiencing hypoglycemia. Providing a snack high in protein and complex carbohydrates can help raise blood glucose levels. A client diagnosed with schizophrenia is experiencing auditory hallucinations. What nursing intervention is most appropriate? Encourage the client to ignore the hallucinations, provide a quiet environment to minimize stimuli, engage in a conversation with the hallucination, or D. Administer an antipsychotic medication as prescribed. The answer is D. Administer an antipsychotic medication as prescribed. Antipsychotic medications are the primary treatment for managing hallucinations in clients with schizophrenia. Administering the prescribed medication is a priority. The nurse is planning a community health education program on preventing cardiovascular disease. What lifestyle modifications should the nurse emphasize? Increase dietary sodium intake. Consume a high-fat diet. Regular physical activity. Smoking sensation. The answer is C, regular physical activity. Regular physical activity is a key lifestyle modification to prevent cardiovascular disease. It helps maintain cardiovascular health and reduces the risk of related complications. A client is prescribed metoprolol for hypertension. The nurse should assess the client for which potential adverse effect? Hypoglycemia, hyperkalemia, bradycardia, or respiratory depression? The answer is C, bradycardia. Metoprolol is a beta blocker that can cause bradycardia as a side effect. Monitoring the client's heart rate is essential. and the nurse should instruct the client to report any signs of bradycardia, such as dizziness or fatigue. A client post-abdominal surgery complains of sudden severe abdominal pain. The nurse notes absent bowel sounds. What complications should the nurse suspect? Paralytic ileus, appendicitis, diverticulitis, or gastroenteritis? The answer is paralytic ileus, A. Absent bowel sounds and sudden, severe abdominal pain suggest paralytic ileus, a common complication after abdominal surgery. It occurs due to decreased gastrointestinal motility. A client with obsessive-compulsive disorder engages in repetitive hand-washing rituals. What nursing intervention is most appropriate? Allow the client to perform the ritual as needed. Set limits on the time allowed for handwashing. Ignore the handwashing behavior. Encourage the client to stop the ritual abruptly. The answer is B. Set limits on the time allowed for handwashing. Setting limits on the time for handwashing helps gradually decrease compulsive behaviors in clients with OCD. It supports a therapeutic approach known as exposure and response prevention. A client at 38 weeks gestation reports leaking fluid from the vagina. What actions should the nurse take first? Perform a sterile speculum examination? Administer oxytocin to induce labor? Place the client in a lateral position? Or assess fetal heart rate? The answer is D. Assess the fetal heart rate. Leaking fluid from the vagina may indicate rupture of membranes. Assessing the fetal heart rate helps, determining the well-being of the fetus before further interventions. A two-year-old client or a two-year-old child is diagnosed with otitis media. What symptoms should a nurse expect during the assessment? Excessive tearing, Presence of carpalic spots, tugging at the air, or dry cracked lips? The answer is C, tugging at the air. Tugging at the air is a common sign of otitis media in young children. It indicates discomfort or pain in the affected ear. A client taking warfarin is prescribed ciprofloxacin, for a urinary tract infection. The nurse should monitor the client for increased bleeding risk, hypertension, hypoglycemia, or hyperkalemia. The answer is increased bleeding risk, A. Ciprofloxacin can potentiate the anticoagulant effects of warfarin, increasing the risk of bleeding. Close monitoring of the client's INR is essential. A client is receiving a blood transfusion and develops chills, fever, and back pain. What action should the nurse take first? Slow down the blood transfusion rate, administer acetaminophen, notify the healthcare provider, or stop the blood transfusion? The answer is D, stop the blood transfusion. The client is exhibiting signs of a transfusion reaction and the blood transfusion should be stopped immediately. The nurse should follow the protocol for managing transfusion reactions per facility. A client with chronic kidney disease is prescribed a phosphate binder. The nurse instructs the client to take the medication with meals, on an empty stomach, at bedtime, every six hours around the clock. The answer is A, with meals. Phosphate binders should be taken with meals to bind dietary phosphate and reduce its absorption. This helps control hyperphosphatemia in clients with chronic kidney disease. A client diagnosed with anorexia nervosa is admitted with a low body weight. What nursing intervention is a priority during the initial phase of treatment? Encourage the client to eat large meals to gain weight quickly. Monitor the client's weight daily without discussion. Allow the client to choose preferred mealtimes. Establish a structured meal plan with small frequent meals. The answer is D. Establish a structured meal plan with small frequent meals. Gradual and structured refeeding is essential in the initial phase of treating anorexia nervosa. A structured meal plan with small frequent meals helps prevent refeeding syndrome. The nurse is conducting a health education session on preventing the spread of sexually transmitted infections in a community. What information should a nurse prioritize? The importance of monogamous relationships, use of barrier methods during sexual activity, frequent testing for STIs, use of hormonal contraceptives for protection. The answer is B, use of barrier methods during sexual activity. Barrier methods such as condoms are effective in preventing the transmission of STIs. Emphasizing their use is a key aspect of STI prevention. A client with heart failure is prescribed Lasix. The nurse should closely monitor the client for which potential side effect. Hyperkalemia, hypokalemia, hyponatremia, or hypernatremia. The answer is B. hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss. Hypokalemia is a potential side effect and the nurse should monitor the client for signs such as muscle weakness and cardiac dysrhythmias. A nurse is caring for an infant with a diagnosis of bronchiolitis. Which intervention is a priority for the nurse to implement? Administer antibiotics as ordered. Administer bronchodilators as ordered, encourage oral fluid intake, or administer corticosteroids as ordered. The answer is C, encourage oral fluid intake. Infants with bronchiolitis are at risk for dehydration due to increased respiratory effort and difficulty feeding. Encouraging oral fluid intake helps maintain hydration. A client diagnosed with major depressive disorder is prescribed with Zoloft. The nurse should instruct the client to take the medication with a full meal, discontinue the medication if mood improves, avoid consuming foods rich in tyramine, or report any signs of serotonin syndrome. The answer is D. Report any signs of serotonin syndrome. Seradiline is a SSRI. and clients should be instructed to report signs of serotonin syndrome, such as agitation, confusion, rapid heartbeat, and fever. The nurse is providing education to a community group about preventing the spread of infectious diseases. What information is most important to include? Proper hand hygiene, strategies for stress reduction, importance of regular exercise, or techniques for healthy cooking? The answer is A, proper hygiene techniques. Proper hygiene is a fundamental measure to prevent the spread of infectious diseases. It is crucial to educate the community about washing hands effectively to reduce the risk of infection. A client at 28 weeks gestation is admitted to the hospital with preterm labor. What intervention is a priority for the nurse to implement? Administer tocolytic medication as ordered. Administer antihypertensive medication as ordered. Prepare the client for a c-section. Administer oxytocin to induce labor. The correct answer is A. Administer tocolytic medication as ordered. Toccolytic medications are used to inhibit uterine contractions and are a priority intervention in managing preterm labor to prevent preterm birth. A client with a history of angina is prescribed nitroglycerin, sublingual tablets. The nurse should instruct the client to swallow the tablet with water, take the tablet on an empty stomach, place the tablet under the tongue when chest pains occur, or take the tablet with a high fat meal? The correct answer is C, place the tablet under the tongue when chest pain occurs. Nitroglycerin sublingual tablets are taken under the tongue to facilitate rapid absorption and provide quick relief of chest pain or angina. A client with chronic kidney disease is prescribed Iopatin Alpha or Procrit. The nurse should educate the client about the purpose of this medication, which is to lower blood pressure, stimulate red blood cell production, improve calcium absorption, or D, reduce the glucose levels. The answer is B, stimulate red blood cell production. Aputin-alpha is a medication that stimulates the production of red blood cells and is often prescribed for clients with CKD experiencing anemia. A client is admitted to this psychiatric unit with symptoms of schizophrenia. The nurse should prioritize which intervention during the initial assessment. Administer PRN sedative to calm the client. Establish a trusting therapeutic relationship. Assessing for symptoms of depression or exploring the client's childhood experiences. The answer is B. Establish a trusting therapeutic relationship. Establishing a trusting therapeutic relationship is a priority in the initial assessment of a client with schizophrenia. It forms the basis for effective communication and care. The nurse is caring for a child diagnosed with acute otitis media. What symptoms should the nurse expect during the assessment? The answer is D, ear pain. Ear pain is a common symptom of acute otitis media in children. The nurse should assess for signs of air pain and discomfort. A client with COPD is prescribed Atrovent. The nurse instructs the client that this medication helps manage COPD by The correct answer is A. Dilating the bronchi. Ipratropium bromide is an anticholinergic bronchodilator that works by dilating the bronchi to improve airflow in clients with COPD. A client diagnosed with bipolar disorder is experiencing a manic episode. What is a priority nursing intervention during this phase? Encourage the client to rest and sleep, provide high-calorie snacks to increase energy, allow the client to engage in goal-directed activities, or set firm limits on disruptive behavior. The correct answer is D. Set firm limits on disruptive behavior. During a manic episode, clients may exhibit impulsive and disruptive behaviors. Setting firm limits helps maintain safety and a therapeutic environment. The nurse is conducting a health promotion class on smoking cessation. Which nicotine replacement therapy method should the nurse recommend as a first-line option? The answer is B, a nicotine patch. Nicotine patches are often recommended as a first-line option for smoking cessation because they provide a steady, controlled release of nicotine to help manage withdrawal symptoms. A client is admitted with a diagnosis of pancreatitis. The nurse anticipates that Primary healthcare provider to prescribe? The answer is A, a low-fat diet. A low-fat diet is commonly prescribed for clients with pancreatitis to reduce stimulation of the pancreas and to decrease the risk of exacerbation. A nurse is assessing a child for dehydration. Which finding is an early sign of dehydration in a pediatric client? The answer is D, tachycardia. Tachycardia is an early sign of dehydration in pediatric clients. As dehydration progresses, other signs such as sunken fontanels, cool extremities, and decreased urine output may become evident. A pregnant client at 28 weeks gestation is admitted with gestational hypertension. The nurse should assess the client for which potential complication? The answer is C, preterm labor. Gestational hypertension is a risk factor for preterm labor. The nurse should monitor the client closely for signs of preterm labor such as uterine contractions. A client diagnosed with GAD or generalized anxiety disorder is prescribed lorazepam. The nurse educates the client about the medication's therapeutic effect, which is to The answer is C, reduce anxiety. Lorazepam is a benzodiazepine that has an anoxic or an anxiety-reducing effect. It is commonly prescribed for the short-term management of anxiety disorders. A client with heart failure is prescribed digoxin. The nurse should monitor the client for signs and symptoms of digoxin toxicity, which include? The answer is B, bradycardia. Digoxin toxicity can manifest with symptoms such as bradycardia, nausea, vomiting, and visual disturbances. Monitoring for these signs is essential in clients taking digoxin. A client is prescribed heparin for deep vein thrombosis, prophylaxis. The nurse should instruct the client that heparin works by dissolving existing blood clots, preventing the formation of new blood clots, inhibiting platelet aggregation, or de-promoting vasodilation. The answer is B, preventing the formation of new blood clots. Heparin is an anticoagulant that works by preventing the formation of new blood clots. It does not dissolve existing clots. but helps prevent the extension of clots and the formation of new ones. A client with diabetes mellitus is prescribed metformin. The nurse should instruct the client to Take the medication with meals. Take the medication on an empty stomach. Discontinue the medication if blood glucose levels are normal. Or take the medication only when experiencing symptoms of hyperglycemia. The answer is A. Take the medication with meals. Metformin is typically taken with meals to reduce the risk of GI side effects. It helps improve insulin sensitivity in clients with diabetes. A client with schizophrenia is prescribed clozapine. The nurse should closely monitor the client for weight gain, photosensitivity, agranulocytosis, or EPS. The correct answer is agranulocytosis. Clozapine is an antipsychotic medication associated with the risk of agranulocytosis, a serious and potentially life-threatening condition characterized by a significant decrease in white blood cell count. The nurse is conducting a home visit for an older adult client. What environment modification should the nurse recommend to enhance safety? Install low pile carpeting, Use non-skid bath mats in the bathroom, increase lighting in dimly lit areas, or arrange furniture in a clutter-free manner? The correct answer is C, increase lighting in dimly lit areas. Increasing lighting in dimly lit areas is crucial to enhance safety for older adults by reducing the risk of falls and improving visibility in the home environment. A client is prescribed aspirin for antiplatelet therapy. The nurse educates the client that aspirin works by inhibiting prostaglandin synthesis, enhancing blood clot formation, increasing platelet aggregation, or dilating blood vessels. The correct answer is A, inhibiting prostaglandin synthesis. Aspirin is an anti-platelet medication that works by inhibiting prostaglandin synthesis, which helps prevent platelet aggregation and blood clot formation. A nurse is assessing a newborn for signs of respiratory distress syndrome. What physical findings is characteristic of RDS in a newborn? Grunting on expiration, Absence of nasal flaring, cyanosis only during feeding, or decreased respiratory rate. The correct answer is grunting on expiration, which is A. This is characteristic in findings in a newborn with respiratory distress syndrome. It is a compensatory mechanism to maintain lung expansion. A pregnant client at 32 weeks gestation is diagnosed with gestational diabetes mellitus. The nurse should anticipate the need for early induction of labor, initiation of insulin therapy, oral hypoglycemic medications, or increased caloric intake. The correct answer is B, initiation of insulin therapy. In some cases of GDM, insulin therapy may be initiated to maintain blood glucose levels within the target range and prevent complications for both the mother and the fetus. A client with major depressive disorder is prescribed fluoxetine. The nurse should educate the client about the delayed onset of therapeutic effects which may take up to 1 week, 2 week, 4 weeks, or 8 weeks. The correct answer is C, 4 weeks. Fluoxetine is a SSRI and may take up to 4 weeks to achieve the full therapeutic effects. Clients should be informed about the delayed onset of action. A client is admitted with acute pancreatitis. The nurse should assess the client for which priority complication? Hyperkalemia, hypoglycemia, hypovalemia, or hypokalcemia? The correct answer is C, hypovolemia. Acute pancreatitis can lead to a fluid shift and hypovolemia. The nurse should monitor the client for signs of dehydration and administer IV fluids as needed. A client with a history of heart failure is prescribed aldactone. The nurse should monitor the client for which potential side effect? Hypokalemia, hyperkalemia, hyponatremia, or hyperanitremia? The correct answer is hyperkalemia B. Spernalactone is a potassium-sparing diuretic, and a potential side effect is hyperkalemia. The nurse should monitor potassium levels and instruct the client to avoid potassium-rich foods. A client with COPD is prescribed teofiline. The nurse should teach the client to avoid excessive consumption of caffeine, calcium, sodium, or potassium. The correct answer is A, caffeine. Teofiline is a bronchodilator that can increase the risk of toxicity when combined with caffeine. The client should be advised to limit caffeine intake. A client is admitted with a suspected diagnosis of Gillian-Barr syndrome. The nurse should assess the client for muscle rigidity, hyperreflexia, ascendant paralysis, or bradycardia. The correct answer is C, ascendant paralysis. Gillian-Barr syndrome is characterized by ascendant paralysis. Starting in the lower extremities and progressing upward, the nurse should monitor for weakness and paralysis. A client with peptic ulcer disease is prescribed ranatidine. The nurse should instruct the client to take the medication before meals, after meals, with meals, or on an empty stomach. The correct answer is A, before meals. Ranatidine is the HD receptor antagonist used to reduce stomach acid. It is most effective when taken before meals to prevent acid production. A client with hypertension is prescribed enolapril. The nurse should instruct the client to monitor for which potential adverse effect. Hypokalemia, hyperkalemia, persistent cough, or weight loss. The correct answer is C, persistent cough. Enolapril, an ACE inhibitor, is associated with a persistent dry cough as a potential adverse effect. The client should report this symptom. A client with a history of TB is prescribed isonazide. The nurse should instruct the client to take the medication with meals, avoid dairy products while on the medication, report yellowing of the skin, or discontinue the medication if symptoms resolve. The correct answer is A, take the medication with meals. Isonazide should be taken with meals to reduce the risk of GI upset. Clients should be instructed not to to discontinue the medication without consulting the healthcare provider. A client is admitted with a suspected pulmonary embolism. The nurse should monitor the client for which common clinical manifestation of pulmonary embolism? Bradycardia, hemoptysis, hypertension, increased breath sounds. The correct answer is B, hemoptysis. Hemoptysis, which is coughing up blood, is a common clinical manifestation of pulmonary embolism. The nurse should assess the client for signs of respiratory distress and bleeding. A nurse is preparing to administer medication to a client. Which action is most important for the nurse to take before administering the medication? Verify the medication order, check the expiration date, ask the client about allergies, or assess the client's vital signs. The correct answer is A. Verify the medication order. Verifying the medication order is the most critical step in medication administration to ensure the right medication, dose, route, and time is taken, is given. A client has a prescription for a low-sodium diet. Which food item should the nurse recommend as a suitable option for the client? Canned soup, fresh fruits, salted nuts, or processed cheese? The correct answer is B. fresh fruits. Fresh fruits are generally low in sodium and a suitable option for your client on a low sodium diet. The nurse is preparing to transfer a client from the bed to a chair. What is the correct technique for the nurse to use during the transfer? Lift the client using the back muscles, bend at the waist while lifting, keep the client's feet close together or use proper body mechanics and a transfer belt. The correct answer is D. Use proper body mechanics and a transfer belt. Using proper body mechanics and a transfer belt helps ensure the safety of both the nurse and the client during transfers. A client has a nasogastric tube in place for gastric decompression. To prevent complications, the nurse should elevate the head of the bed, clamp the tube, use a small diameter suction catheter, or administer medications directly through the tube? The correct answer is A, elevate the head of the bed to at least 45 degrees. Elevating the head of the bed helps prevent reflux and aspiration in clients with a nasogastric tube. A client is experiencing dyspnea and anxiety. What is the nurse's priority action? Administer a sedative medication? Assess the client's oxygen? Encourage deep breathing exercise or provide a cold glass of water? A glass of cold water. The correct answer is B. Assess the client's oxygen saturation. Assessing the client's oxygen saturation is the priority to determine the severity of their respiratory distress and guide appropriate interventions. A client is prescribed sub-q heparin for DVT prophylaxis. What is essential for the nurse to monitor in the client? Blood pressure, respiratory rate, APTT, or serum potassium levels? The correct answer is activated partial thromboplasm time or APTT. Monitoring the APTT is essential to assess the therapeutic range and prevent complications in clients receiving heparin. A client has a wound that is healing by secondary intention. The nurse understands that healing by secondary intention involves minimal tissue loss, epithelial cell migration, scar formation without granulation tissue, or wound edges brought together with sutures. The correct answer is B, epithelial cell migration. Healing by secondary intention involves the formation of granulation tissue and epithelial cell migration to fill the wound. as seen in open wounds with tissue loss. The nurse is caring for a client who is immobile. To prevent complications, what intervention is most important for the nurse to implement? Encourage a high-protein diet. Apply compression stockings, provide range of motion exercises, or elevate the client's legs? The correct answer is C, provide range of motion exercises. Range of motion exercises helps prevent complications of immobility, such as muscle atrophy and joint contractures. A client with a history of heart failure is admitted to the hospital with acute decompensation. The nurse notes crackles in the lungs, jugular vein distension, and peripheral edema. The client is dyspneic and reports a weight gain of 5 pounds over the past two days. The nurse recognizes these findings as indicative of worsening heart failure. What is the primary goal of initial management for a client with acute, decompensated heart failure experiencing fluid overload? The correct answer is A, administer loop diuretics to promote diuresis. By administering loop diuretics in this setting of acute decompensated heart failure with fluid overload, the primary goal of initial management is to reduce the fluid volume and relieve the symptoms. Loop diuretics such as furosemide are commonly used to promote diuresis and reduce excessive fluid retention. Diuresis helps alleviate pulmonary congestion, which is crackles in the lungs, decrease JVD, jugular venous distension, and reduce peripheral edema. Loop diuretics acts on the loop of helpni in the kidneys, promoting the excretion of sodium and water. A client with type 1 diabetes is prescribed regular insulin and NPH insulin. The nurse should instruct the client to administer insulin in which order? The correct answer is B, regular insulin followed by NPH insulin. The correct administration order for regular insulin, which is the short acting, and NPH, which is intermediate acting, is to draw up and administer the regular insulin first, followed by the NPH insulin. This sequence ensures that the rapid-active insulin is with hyperthyroidism. The nurse should assess the client for which common clinical manifestation? Bradycardia, weight gain, cold intolerance, or exoprothalamus? The correct answer is D, exoprothalamus. Exoprothalamus or protruding eyeballs is a characteristic sign of hyperthyroidism, particularly in conditions like grave disease. Other manifestations of hyperthyroidism include tachycardia, weight loss, and heat intolerance. A client with Addison's disease is at risk for adrenal crisis. The nurse should monitor for which critical sign of adrenal crisis? Hypertension, hyperglycemia, hypovolemia, or hypokalemia? The correct answer is C, hypovolemia. Adrenal crisis in clients with Addison's disease is characterized by severe hypovolemia, which can lead to hypotension, dehydration, and shock. Prompt recognition and intervention are crucial to prevent life-threatening complications. A client with diabetes insipidus is prescribed desmopressin, acetate. The nurse should monitor the client for signs of hypoglycemia, fluid retention, hyperkalemia, or decreased urine output. The correct answer is B, fluid retention. Desmopressin acetate is a synthetic form of ADH used to treat diabetes insipidus. ADH, when I say ADH, I mean antithyroidic hormone. It promotes water reabsorption in the kidneys, leading to fluid retention. Monitoring for signs of hyponatremia and fluid overload is important during therapy. A client with hypothyroidism is prescribed levothyroxine. The nurse should instruct the client to take the medication with meals, on an empty stomach in the morning, before bedtime, or concurrently with calcium supplements. The correct answer is B, on an empty stomach in the morning. Levothyroxine absorption is optimal when taken on an empty stomach, preferably in the morning. It should be taken at least 30 minutes before eating or taken other medications to ensure proper absorption. Concurrent administration with calcium supplements can interfere with absorption. A client with Cushion syndrome is at risk for developing osteoporosis due to long-term exposure to excess cortisol. The nurse should recommend which intervention to mitigate this risk. Encourage weight-bearing exercises, limit vitamin D intake, promote a low-calcium diet, or restrict fluid intake. The correct answer is A, encourage weight-bearing exercises. Weight-bearing exercises such as walking or resistance training can help mitigate the risk of osteoporosis in clients with Cushing syndrome. Adequate calcium and vitamin D intake are also important for bone health. A client is diagnosed with hyperparathyroidism. The nurse should assess the client for which electrolyte imbalance commonly associated with this condition. Hyperkalemia, hypocalcemia, hyponatremia, or hypophosphatemia. The correct answer is B, hypocalcemia. Hyperparathyroidism can lead to increased release of parathyroid hormone. resulted in elevated calcium levels and hypocalcemia. Clients may experience symptoms such as muscle cramps, tingling, and spasms. A client with pheochromocytoma is admitted to the hospital. The nurse should assess the client for which characteristic signs and symptoms of this condition. The correct answer is A, hypertension, diaphoresis, and palpitations. Pheochromocytoma is characterized by the overproduction of catecholamines, leading to symptoms such as severe hypertension, diaphoresis, palpitations, and headaches. A client in the ICU has a central venous catheter in place. The nurse notes redness, swelling, warmth at the insertion site. The client's temperature is elevated. What is the priority nurse in action? The correct answer is C. remove the central venous catheter. The client's symptoms include redness, swelling, and warmth, and an elevated temperature at the central venous catheter site, which suggests a possible infection. The priority action is to remove the catheter to prevent further systemic infection and complications. A client in respiratory distress is admitted to the ER. The nurse auscultates wheezing, observes the use of accessory muscles, and notes a decreased level of consciousness. What is the initial nursing intervention? The correct answer is A, administer oxygen therapy. The initial priority in respiratory distress is to ensure adequate oxygenation. Administering oxygen therapy is the first step to improve oxygen saturation. Further interventions such as bronchodilators or endotracheal intubation may be necessary based on the client's response. A client in the CCU is monitored for dysrhythmias. The nurse observes a sudden onset of irregular chaotic heartbeats on the cardiac monitor. The client is unresponsive. What is the immediate nursing action? The correct answer is A, begin chest compressions. The sudden onset of irregular chaotic heartbeats, ventricular fib, Requires the immediate initiation of CPR with chest compressions. This is a life-threatening dysrhythmia and prompt intervention is crucial. A client with a neurological intensive care unit has increased intracranial pressure. The nurse should prioritize which intervention to reduce ICP. The correct answer is B. Administer hypertonic saline. Hypertonic saline is often used to reduce intracranial pressure by drawing fluid out of the brain cells. Elevating the head of the bed, coughing, and deep breathing may be beneficial, but administering hypertonic saline is the priority. A postoperative surgical client in the post-anesthesia unit is receiving intravenous opioids for pain control. The nurse observes the client's respiratory rate decreasing to 8. breaths per minute. What is the initial nursing action? Administer naloxone, increase the opioid infusion rate, assess the client's pain level, or D, apply oxygen via nasal cannula. A significant decrease in respiratory rate following opioid administration may indicate opioid overdose, so the correct answer is A, administer naloxone. The initial action is to administer naloxone, an opioid antagonist, to reverse the effects of the opioid and restore adequate ventilation. A client in the ICU is receiving a continuous IV infusion, intravenous infusion, of a vasoactive medication to maintain blood pressure. The nurse notes a sudden drop in blood pressure and an increase in heart rate. What is the priority nursing action? The correct answer is C, notify the healthcare provider immediately. A sudden drop in blood pressure and an increase in heart rate may indicate a potential adverse reaction to the vasoactive medication. The priority action is to notify the healthcare provider for further assessment and guidance. A client with acute respiratory distress syndrome is receiving mechanical ventilation. The nurse observes a decrease in breath sounds on one side. and the chest tube on that side appears hyperresonant. What is the priority nursing action? The correct answer is D, notify the healthcare provider immediately. A decrease in breath sounds on one side and hyperresonance may indicate a pneumothorax, a potentially life-threatening complication. The priority action is to notify the healthcare provider for prompt evaluation and intervention. A client in the neurological intensive care unit has a Glasgow Coma Scale score of 8. The nurse should prioritize which intervention? The correct answer is A, assess the pupillary response. A GCS score of 8 indicates a decreased level of consciousness. Assessing pupillary response is a critical nursing intervention to monitor neurological status. Changes in pupillary size or reactivity can provide important information about the client's condition. A client admitted to the MedSurg ICU is at risk for developing acute respiratory distress syndrome. The nurse should identify which condition as a common risk factor for ARDS. The correct answer is C, sepsis. Sepsis is a common risk factor for the development of ARDS. Other risk factors may include trauma, pneumonia, and aspiration of gastric contents. Early recognition and management of sepsis are crucial in preventing ARDS. A client with chronic renal failure is prescribed a low-protein diet. The nurse should educate the client about the importance of restricting which specific nutrient. The correct answer is D, phosphorus. In chronic renal failure, there is impaired excretion of phosphorus, leading to hyperphosphatemia. Restricting dietary phosphorus is crucial to manage the condition and prevent complications such as bone and mineral disorders. A client is admitted with suspected acute pancreatitis. The nurse should monitor the client for which classic sign of this condition. The correct answer is C, jaundice. Jaundice is a classic sign of acute pancreatitis, indicating obstruction of the common bile duct due to inflammation. Other common signs include severe abdominal pain, nausea, and vomiting. A client with heart failure is prescribed furosemide. The nurse should monitor the client for which potential electrolyte imbalance is associated with this medication. The correct answer is D, hypomagnesemia. Furosemide is a loop diuretic that can lead to the loss of magnesium resulting in hypomagnesemia. The nurse should monitor magnesium levels and educate the client about magnesium-rich foods. A client with diabetes mellitus is admitted with a foot ulcer. The nurse should prioritize which intervention to promote wound healing. The correct answer is D, maintaining strict blood glucose control. Strike blood glucose control is crucial for promoting wound healing in clients with diabetes mellitus. Elevated blood glucose levels can impair the healing process and increase the risk of infection. Controlling blood glucose helps optimize conditions for tissue repair. A client is admitted with a suspected gastrointestinal bleed. The nurse observes black tarry stools. What is the priority nursing action? The correct answer is A. Obtain a stool sample for cold blood testing. Black tarry stools, melina, can indicate gastrointestinal bleeding. The priority action is to obtain a stool sample for cold blood testing to confirm the presence of blood and determine the source of bleeding. A client is scheduled for surgery to remove a thyroid tumor. The nurse should assess the client for signs and symptoms of which potential complication. The correct answer is C, hypocalcemia. Surgical removal of the thyroid gland poses a risk of damaging the parathyroid glands, leading to hypocalcemia. The nurse should monitor for signs of hypocalcemia such as tetany, numbness and tingling and collaborate with a healthcare provider for calcium supplements if needed. A client with rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which potential side effect of this medication. The correct answer is B, liver toxicity. Methotrexate commonly used to treat rheumatoid arthritis can cause liver toxicity. The nurse should monitor liver function regularly and educate the client about signs of liver dysfunction such as jaundice and abdominal pain. A pregnant client is at 32 weeks gestation and reports abdominal pain. The nurse notes uterine contractions on a monitor. What is the priority nurse in action? The correct answer is B. Place the client in a left lateral position. Placing the client in a left lateral position helps optimize uterine perfusion and is a priority intervention when uterine contractions are noted, especially in the third trimester. This position improves blood flow to the placenta and reduces pressure on the vena cava. The nurse is planning a health promotion program for a community. Which strategy is most effective in promoting behavior change? The correct answer is B. B. Conducting community workshops and demonstrations. Conducting community workshops and demonstrations is a more interactive and engaging strategy, promoting active participation and better retention of health information. A client prescribed Coumadin for DVT. The nurse should instruct the client about the importance of... The correct answer is C. Consistent intake of foods high in vitamin K. Warfarin interacts with vitamin K and consistent intake of foods high in vitamin K help maintain the stability of the medication. Clients should not avoid vitamin K but rather consume a consistent amount to maintain the therapeutic effects of warfarin. A client is admitted with severe dehydration. The nurse is planning care and knows that a priority intervention is to? The correct answer is C. Assess Skin Turgor and Mucus Membranes. Assessing Skin Turgor and Mucus Membranes provides valuable information about the degree of dehydration. This initial assessment helps determine the severity of dehydration and guides subsequent interventions. A client with COPD is prescribed a bronchodilator therapy. The nurse should instruct the client to use the bronchodilator. The correct answer is B. Daily at the same time each morning. Bronchodilators for COPD are often prescribed on a scheduled basis to maintain bronchodilation and improve airflow. Using the medication daily at the same time helps establish your routine and optimize its effectiveness. The nurse is participating in a multidisciplinary team meeting. What is the primary purpose of a multidisciplinary team? in a healthcare setting? The correct answer is B, problem solving and decision making. The primary purpose of multidisciplinary team in healthcare is to bring together individuals with different expertise to collaborate to solve problems and make decisions that benefit patient care. A community health nurse is conducting a needs assessment for a specific population. Which step? should a nurse take first in the assessment process? The correct answer is C, define the target population. Defining the target population is the initial step in a needs assessment. This step helps focus the assessment on the specific group that will benefit from the community health intervention. A client with depression is prescribed a SSRI. The nurse should educate the client about the need to monitor for... The correct answer is C, suicidal ideation. SSRIs are commonly prescribed for depression, and the client should be monitored for the emergence of suicidal ideation, especially in the initial weeks of treatment. The nurse should instruct the client to report any changes in mood or thoughts immediately. A client is admitted with a suspected MI. The nurse should assess the client for which classic symptom of MI? The correct answer is D, crushing substernal chest pain. The classic symptom of MI or heart attack is crushing substernal chest pain that may radiate to the left arm or jaw. This type of chest pain is often described as intense and pressure-like. A client with schizophrenia is prescribed risperidone. The nurse should educate the client about the potential effect of the correct answer is A, weight gain. Weight gain is a potential side effect of risperidone, an atypical antipsychotic. The nurse should educate the client about the importance of monitoring weight gain and adopting a healthy lifestyle. A client with respiratory infection is placed on contact precautions. What is the most appropriate personal protective equipment for the nurse to wear when entering the client's room? The correct answer is A, gown and gloves. Contact precautions require the use of gown and gloves to prevent the transmission of infectious agents. Additional PPE such as mask and goggles may be needed based on the specific situation, but gowns and gloves are the minimum requirement. A client is admitted with a diagnosis of pneumonia. The nurse is assessing the client's respiratory status. Which finding requires immediate intervention? The correct answer is D, inspiratory crackles heard on auscultation. Inspiratory crackles suggest fluid in the alveoli or bronchioles and may indicate a worsening respiratory status. Immediate intervention is needed to address potential respiratory distress. A nurse is caring for a client with a new tracheostomy. What is the priority nursing action to maintain airway patency? The correct answer is A, suctioning the tracheostomy tube every four hours. Regular suctioning of the tracheostomy tube is essential to maintain airway patency and prevent the accumulation of secretions. This helps ensure effective breathing for the client with a tracheostomy. A pregnant client is at 28 weeks gestation and reports sudden severe abdominal pain. The nurse notes vaginal bleeding and signs of shock. What is the priority nursing action? The correct answer is C, preparing for an emergency C-section. The sudden onset of severe abdominal pain, vaginal bleeding, and signs of shock are indicative of a potential abrupt geoplacenta. This is a medical emergency and the priority nursing action is to prepare for an emergency cesarean section to deliver the fetus promptly and address the maternal and fetal distress. Immediate intervention is essential to optimize outcomes for both the mother and the baby. Thank you for tuning in to MedNurse Farm. Please remember, please leave a comment below, share this video, subscribe and like and turn on your notification button. I look forward to hearing about your success in passing your HESI exam.

Withhold the digoxin. C. Increase the digoxin dose.

Or D. Encourage a diet high in sodium. The answer is B. Withhold the digoxin.

Hypokalemia increases the risk of digoxin toxicity. Withholding the digoxin and addressing the low potassium level is the priority to prevent adverse effects. A client post-thyroidectomy develops tingling around the mouth and fingers.

What action should a nurse take first? A. Administer calcium gluconate. B.

Increase the IV fluid rate. C. Notify the healthcare provider or D. Document the finding.

The answer is A. Administer calcium gluconate. Tingling around the mouth and fingers may indicate hypocalcemia, a potential complication post-thyroidectomy.

Administering calcium gluconate is a rapid intervention to address low calcium levels. A client with major depressive disorder is started on Sertraline. The nurse provides education about the medication, emphasizing the need to A.

Take the medication with food B. Abruptly stop the medication if side effects occur C. Expect immediate improvement in mood or D. Avoid concurrent use of other antidepressants. The answer is D.

Avoid concurrent use of other antidepressants. Concurrent use of multiple antidepressants can lead to serotonin syndrome. Educating the client about potential interactions and the importance of avoiding other antidepressants is crucial. A pregnant client is diagnosed with preeclampsia.

What assessment finding is indicative of severe preeclampsia? A. proteinuria, B.

Blood pressure of 140 over 90, C. Presence of ankle edemia, or D. Epigastric pain. The answer is D.

Epigastric pain. Epigastric pain is a sign of severe preeclampsia and may indicate liver involvement. It requires prompt intervention and close monitoring. The nurse is assessing a toddler with suspected dehydration. What finding is indicative of moderate dehydration?

A. Capillary refill less than two seconds. B. Sunken fontanels.

C. Increased urine output or D. Weight gain. The answer is B. Sunken fontanels.

Sunken fontanels are a sign of moderate dehydration in a toddler. It indicates decreased fluid volume and warrants further assessment and intervention. A client receiving heparin therapy reports unusual bleeding, including nosebleeds and blood in the urine.

What action should a nurse take? A. Administer vitamin K.

B. Monitor platelet count. C. Increase the heparin dose. D.

Administer protamine sulfate. The answer is B. Monitor platelet count. Unusual bleeding may indicate heparin-induced thrombocytopenia, or HIT. Monitoring the platelet count is essential to assess for this potentially serious complication.

A client with chronic obstructive pulmonary disease is prescribed oxygen therapy. What should a nurse monitor for as a potential side effect of oxygen therapy? Increased respiratory rate, elevated blood pressure, decreased level of consciousness, or dry mucous membranes?

The answer is A, increased respiratory rate. Oxygen therapy can suppress the hypoxic drive in clients with COPD, leading to a decreased respiratory rate. Monitoring for respiratory changes is therefore essential. A client with type 1 diabetes reports feeling shaky, sweaty, and anxious. What interventions should a nurse implement?

Administer glucagon, provide a snack high in protein, administer regular insulin, or increase the frequency of insulin injections. The answer is B, provide a snack high in protein. The client is likely experiencing hypoglycemia. Providing a snack high in protein and complex carbohydrates can help raise blood glucose levels. A client diagnosed with schizophrenia is experiencing auditory hallucinations.

What nursing intervention is most appropriate? Encourage the client to ignore the hallucinations, provide a quiet environment to minimize stimuli, engage in a conversation with the hallucination, or D. Administer an antipsychotic medication as prescribed.

The answer is D. Administer an antipsychotic medication as prescribed. Antipsychotic medications are the primary treatment for managing hallucinations in clients with schizophrenia.

Administering the prescribed medication is a priority. The nurse is planning a community health education program on preventing cardiovascular disease. What lifestyle modifications should the nurse emphasize?

Increase dietary sodium intake. Consume a high-fat diet. Regular physical activity.

Smoking sensation. The answer is C, regular physical activity. Regular physical activity is a key lifestyle modification to prevent cardiovascular disease. It helps maintain cardiovascular health and reduces the risk of related complications.

A client is prescribed metoprolol for hypertension. The nurse should assess the client for which potential adverse effect? Hypoglycemia, hyperkalemia, bradycardia, or respiratory depression?

The answer is C, bradycardia. Metoprolol is a beta blocker that can cause bradycardia as a side effect. Monitoring the client's heart rate is essential.

and the nurse should instruct the client to report any signs of bradycardia, such as dizziness or fatigue. A client post-abdominal surgery complains of sudden severe abdominal pain. The nurse notes absent bowel sounds. What complications should the nurse suspect?

Paralytic ileus, appendicitis, diverticulitis, or gastroenteritis? The answer is paralytic ileus, A. Absent bowel sounds and sudden, severe abdominal pain suggest paralytic ileus, a common complication after abdominal surgery. It occurs due to decreased gastrointestinal motility.

A client with obsessive-compulsive disorder engages in repetitive hand-washing rituals. What nursing intervention is most appropriate? Allow the client to perform the ritual as needed.

Set limits on the time allowed for handwashing. Ignore the handwashing behavior. Encourage the client to stop the ritual abruptly. The answer is B.

Set limits on the time allowed for handwashing. Setting limits on the time for handwashing helps gradually decrease compulsive behaviors in clients with OCD. It supports a therapeutic approach known as exposure and response prevention.

A client at 38 weeks gestation reports leaking fluid from the vagina. What actions should the nurse take first? Perform a sterile speculum examination?

Administer oxytocin to induce labor? Place the client in a lateral position? Or assess fetal heart rate? The answer is D. Assess the fetal heart rate.

Leaking fluid from the vagina may indicate rupture of membranes. Assessing the fetal heart rate helps, determining the well-being of the fetus before further interventions. A two-year-old client or a two-year-old child is diagnosed with otitis media.

What symptoms should a nurse expect during the assessment? Excessive tearing, Presence of carpalic spots, tugging at the air, or dry cracked lips? The answer is C, tugging at the air. Tugging at the air is a common sign of otitis media in young children. It indicates discomfort or pain in the affected ear.

A client taking warfarin is prescribed ciprofloxacin, for a urinary tract infection. The nurse should monitor the client for increased bleeding risk, hypertension, hypoglycemia, or hyperkalemia. The answer is increased bleeding risk, A. Ciprofloxacin can potentiate the anticoagulant effects of warfarin, increasing the risk of bleeding. Close monitoring of the client's INR is essential.

A client is receiving a blood transfusion and develops chills, fever, and back pain. What action should the nurse take first? Slow down the blood transfusion rate, administer acetaminophen, notify the healthcare provider, or stop the blood transfusion? The answer is D, stop the blood transfusion.

The client is exhibiting signs of a transfusion reaction and the blood transfusion should be stopped immediately. The nurse should follow the protocol for managing transfusion reactions per facility. A client with chronic kidney disease is prescribed a phosphate binder. The nurse instructs the client to take the medication with meals, on an empty stomach, at bedtime, every six hours around the clock.

The answer is A, with meals. Phosphate binders should be taken with meals to bind dietary phosphate and reduce its absorption. This helps control hyperphosphatemia in clients with chronic kidney disease. A client diagnosed with anorexia nervosa is admitted with a low body weight.

What nursing intervention is a priority during the initial phase of treatment? Encourage the client to eat large meals to gain weight quickly. Monitor the client's weight daily without discussion.

Allow the client to choose preferred mealtimes. Establish a structured meal plan with small frequent meals. The answer is D. Establish a structured meal plan with small frequent meals.

Gradual and structured refeeding is essential in the initial phase of treating anorexia nervosa. A structured meal plan with small frequent meals helps prevent refeeding syndrome. The nurse is conducting a health education session on preventing the spread of sexually transmitted infections in a community. What information should a nurse prioritize?

The importance of monogamous relationships, use of barrier methods during sexual activity, frequent testing for STIs, use of hormonal contraceptives for protection. The answer is B, use of barrier methods during sexual activity. Barrier methods such as condoms are effective in preventing the transmission of STIs. Emphasizing their use is a key aspect of STI prevention. A client with heart failure is prescribed Lasix.

The nurse should closely monitor the client for which potential side effect. Hyperkalemia, hypokalemia, hyponatremia, or hypernatremia. The answer is B. hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss.

Hypokalemia is a potential side effect and the nurse should monitor the client for signs such as muscle weakness and cardiac dysrhythmias. A nurse is caring for an infant with a diagnosis of bronchiolitis. Which intervention is a priority for the nurse to implement? Administer antibiotics as ordered.

Administer bronchodilators as ordered, encourage oral fluid intake, or administer corticosteroids as ordered. The answer is C, encourage oral fluid intake. Infants with bronchiolitis are at risk for dehydration due to increased respiratory effort and difficulty feeding.

Encouraging oral fluid intake helps maintain hydration. A client diagnosed with major depressive disorder is prescribed with Zoloft. The nurse should instruct the client to take the medication with a full meal, discontinue the medication if mood improves, avoid consuming foods rich in tyramine, or report any signs of serotonin syndrome.

The answer is D. Report any signs of serotonin syndrome. Seradiline is a SSRI. and clients should be instructed to report signs of serotonin syndrome, such as agitation, confusion, rapid heartbeat, and fever. The nurse is providing education to a community group about preventing the spread of infectious diseases.

What information is most important to include? Proper hand hygiene, strategies for stress reduction, importance of regular exercise, or techniques for healthy cooking? The answer is A, proper hygiene techniques.

Proper hygiene is a fundamental measure to prevent the spread of infectious diseases. It is crucial to educate the community about washing hands effectively to reduce the risk of infection. A client at 28 weeks gestation is admitted to the hospital with preterm labor.

What intervention is a priority for the nurse to implement? Administer tocolytic medication as ordered. Administer antihypertensive medication as ordered.

Prepare the client for a c-section. Administer oxytocin to induce labor. The correct answer is A.

Administer tocolytic medication as ordered. Toccolytic medications are used to inhibit uterine contractions and are a priority intervention in managing preterm labor to prevent preterm birth. A client with a history of angina is prescribed nitroglycerin, sublingual tablets. The nurse should instruct the client to swallow the tablet with water, take the tablet on an empty stomach, place the tablet under the tongue when chest pains occur, or take the tablet with a high fat meal? The correct answer is C, place the tablet under the tongue when chest pain occurs.

Nitroglycerin sublingual tablets are taken under the tongue to facilitate rapid absorption and provide quick relief of chest pain or angina. A client with chronic kidney disease is prescribed Iopatin Alpha or Procrit. The nurse should educate the client about the purpose of this medication, which is to lower blood pressure, stimulate red blood cell production, improve calcium absorption, or D, reduce the glucose levels. The answer is B, stimulate red blood cell production. Aputin-alpha is a medication that stimulates the production of red blood cells and is often prescribed for clients with CKD experiencing anemia.

A client is admitted to this psychiatric unit with symptoms of schizophrenia. The nurse should prioritize which intervention during the initial assessment. Administer PRN sedative to calm the client. Establish a trusting therapeutic relationship. Assessing for symptoms of depression or exploring the client's childhood experiences.

The answer is B. Establish a trusting therapeutic relationship. Establishing a trusting therapeutic relationship is a priority in the initial assessment of a client with schizophrenia.

It forms the basis for effective communication and care. The nurse is caring for a child diagnosed with acute otitis media. What symptoms should the nurse expect during the assessment?

The answer is D, ear pain. Ear pain is a common symptom of acute otitis media in children. The nurse should assess for signs of air pain and discomfort. A client with COPD is prescribed Atrovent. The nurse instructs the client that this medication helps manage COPD by The correct answer is A.

Dilating the bronchi. Ipratropium bromide is an anticholinergic bronchodilator that works by dilating the bronchi to improve airflow in clients with COPD. A client diagnosed with bipolar disorder is experiencing a manic episode. What is a priority nursing intervention during this phase?

Encourage the client to rest and sleep, provide high-calorie snacks to increase energy, allow the client to engage in goal-directed activities, or set firm limits on disruptive behavior. The correct answer is D. Set firm limits on disruptive behavior.

During a manic episode, clients may exhibit impulsive and disruptive behaviors. Setting firm limits helps maintain safety and a therapeutic environment. The nurse is conducting a health promotion class on smoking cessation. Which nicotine replacement therapy method should the nurse recommend as a first-line option? The answer is B, a nicotine patch.

Nicotine patches are often recommended as a first-line option for smoking cessation because they provide a steady, controlled release of nicotine to help manage withdrawal symptoms. A client is admitted with a diagnosis of pancreatitis. The nurse anticipates that Primary healthcare provider to prescribe? The answer is A, a low-fat diet. A low-fat diet is commonly prescribed for clients with pancreatitis to reduce stimulation of the pancreas and to decrease the risk of exacerbation.

A nurse is assessing a child for dehydration. Which finding is an early sign of dehydration in a pediatric client? The answer is D, tachycardia.

Tachycardia is an early sign of dehydration in pediatric clients. As dehydration progresses, other signs such as sunken fontanels, cool extremities, and decreased urine output may become evident. A pregnant client at 28 weeks gestation is admitted with gestational hypertension.

The nurse should assess the client for which potential complication? The answer is C, preterm labor. Gestational hypertension is a risk factor for preterm labor.

The nurse should monitor the client closely for signs of preterm labor such as uterine contractions. A client diagnosed with GAD or generalized anxiety disorder is prescribed lorazepam. The nurse educates the client about the medication's therapeutic effect, which is to The answer is C, reduce anxiety.

Lorazepam is a benzodiazepine that has an anoxic or an anxiety-reducing effect. It is commonly prescribed for the short-term management of anxiety disorders. A client with heart failure is prescribed digoxin. The nurse should monitor the client for signs and symptoms of digoxin toxicity, which include? The answer is B, bradycardia.

Digoxin toxicity can manifest with symptoms such as bradycardia, nausea, vomiting, and visual disturbances. Monitoring for these signs is essential in clients taking digoxin. A client is prescribed heparin for deep vein thrombosis, prophylaxis. The nurse should instruct the client that heparin works by dissolving existing blood clots, preventing the formation of new blood clots, inhibiting platelet aggregation, or de-promoting vasodilation. The answer is B, preventing the formation of new blood clots.

Heparin is an anticoagulant that works by preventing the formation of new blood clots. It does not dissolve existing clots. but helps prevent the extension of clots and the formation of new ones. A client with diabetes mellitus is prescribed metformin. The nurse should instruct the client to Take the medication with meals.

Take the medication on an empty stomach. Discontinue the medication if blood glucose levels are normal. Or take the medication only when experiencing symptoms of hyperglycemia.

The answer is A. Take the medication with meals. Metformin is typically taken with meals to reduce the risk of GI side effects. It helps improve insulin sensitivity in clients with diabetes.

A client with schizophrenia is prescribed clozapine. The nurse should closely monitor the client for weight gain, photosensitivity, agranulocytosis, or EPS. The correct answer is agranulocytosis. Clozapine is an antipsychotic medication associated with the risk of agranulocytosis, a serious and potentially life-threatening condition characterized by a significant decrease in white blood cell count.

The nurse is conducting a home visit for an older adult client. What environment modification should the nurse recommend to enhance safety? Install low pile carpeting, Use non-skid bath mats in the bathroom, increase lighting in dimly lit areas, or arrange furniture in a clutter-free manner?

The correct answer is C, increase lighting in dimly lit areas. Increasing lighting in dimly lit areas is crucial to enhance safety for older adults by reducing the risk of falls and improving visibility in the home environment. A client is prescribed aspirin for antiplatelet therapy.

The nurse educates the client that aspirin works by inhibiting prostaglandin synthesis, enhancing blood clot formation, increasing platelet aggregation, or dilating blood vessels. The correct answer is A, inhibiting prostaglandin synthesis. Aspirin is an anti-platelet medication that works by inhibiting prostaglandin synthesis, which helps prevent platelet aggregation and blood clot formation. A nurse is assessing a newborn for signs of respiratory distress syndrome. What physical findings is characteristic of RDS in a newborn?

Grunting on expiration, Absence of nasal flaring, cyanosis only during feeding, or decreased respiratory rate. The correct answer is grunting on expiration, which is A. This is characteristic in findings in a newborn with respiratory distress syndrome.

It is a compensatory mechanism to maintain lung expansion. A pregnant client at 32 weeks gestation is diagnosed with gestational diabetes mellitus. The nurse should anticipate the need for early induction of labor, initiation of insulin therapy, oral hypoglycemic medications, or increased caloric intake.

The correct answer is B, initiation of insulin therapy. In some cases of GDM, insulin therapy may be initiated to maintain blood glucose levels within the target range and prevent complications for both the mother and the fetus. A client with major depressive disorder is prescribed fluoxetine. The nurse should educate the client about the delayed onset of therapeutic effects which may take up to 1 week, 2 week, 4 weeks, or 8 weeks. The correct answer is C, 4 weeks.

Fluoxetine is a SSRI and may take up to 4 weeks to achieve the full therapeutic effects. Clients should be informed about the delayed onset of action. A client is admitted with acute pancreatitis.

The nurse should assess the client for which priority complication? Hyperkalemia, hypoglycemia, hypovalemia, or hypokalcemia? The correct answer is C, hypovolemia.

Acute pancreatitis can lead to a fluid shift and hypovolemia. The nurse should monitor the client for signs of dehydration and administer IV fluids as needed. A client with a history of heart failure is prescribed aldactone. The nurse should monitor the client for which potential side effect? Hypokalemia, hyperkalemia, hyponatremia, or hyperanitremia?

The correct answer is hyperkalemia B. Spernalactone is a potassium-sparing diuretic, and a potential side effect is hyperkalemia. The nurse should monitor potassium levels and instruct the client to avoid potassium-rich foods. A client with COPD is prescribed teofiline. The nurse should teach the client to avoid excessive consumption of caffeine, calcium, sodium, or potassium.

The correct answer is A, caffeine. Teofiline is a bronchodilator that can increase the risk of toxicity when combined with caffeine. The client should be advised to limit caffeine intake.

A client is admitted with a suspected diagnosis of Gillian-Barr syndrome. The nurse should assess the client for muscle rigidity, hyperreflexia, ascendant paralysis, or bradycardia. The correct answer is C, ascendant paralysis. Gillian-Barr syndrome is characterized by ascendant paralysis.

Starting in the lower extremities and progressing upward, the nurse should monitor for weakness and paralysis. A client with peptic ulcer disease is prescribed ranatidine. The nurse should instruct the client to take the medication before meals, after meals, with meals, or on an empty stomach.

The correct answer is A, before meals. Ranatidine is the HD receptor antagonist used to reduce stomach acid. It is most effective when taken before meals to prevent acid production. A client with hypertension is prescribed enolapril. The nurse should instruct the client to monitor for which potential adverse effect.

Hypokalemia, hyperkalemia, persistent cough, or weight loss. The correct answer is C, persistent cough. Enolapril, an ACE inhibitor, is associated with a persistent dry cough as a potential adverse effect.

The client should report this symptom. A client with a history of TB is prescribed isonazide. The nurse should instruct the client to take the medication with meals, avoid dairy products while on the medication, report yellowing of the skin, or discontinue the medication if symptoms resolve. The correct answer is A, take the medication with meals. Isonazide should be taken with meals to reduce the risk of GI upset.

Clients should be instructed not to to discontinue the medication without consulting the healthcare provider. A client is admitted with a suspected pulmonary embolism. The nurse should monitor the client for which common clinical manifestation of pulmonary embolism?

Bradycardia, hemoptysis, hypertension, increased breath sounds. The correct answer is B, hemoptysis. Hemoptysis, which is coughing up blood, is a common clinical manifestation of pulmonary embolism.

The nurse should assess the client for signs of respiratory distress and bleeding. A nurse is preparing to administer medication to a client. Which action is most important for the nurse to take before administering the medication?

Verify the medication order, check the expiration date, ask the client about allergies, or assess the client's vital signs. The correct answer is A. Verify the medication order. Verifying the medication order is the most critical step in medication administration to ensure the right medication, dose, route, and time is taken, is given.

A client has a prescription for a low-sodium diet. Which food item should the nurse recommend as a suitable option for the client? Canned soup, fresh fruits, salted nuts, or processed cheese?

The correct answer is B. fresh fruits. Fresh fruits are generally low in sodium and a suitable option for your client on a low sodium diet. The nurse is preparing to transfer a client from the bed to a chair. What is the correct technique for the nurse to use during the transfer?

Lift the client using the back muscles, bend at the waist while lifting, keep the client's feet close together or use proper body mechanics and a transfer belt. The correct answer is D. Use proper body mechanics and a transfer belt. Using proper body mechanics and a transfer belt helps ensure the safety of both the nurse and the client during transfers.

A client has a nasogastric tube in place for gastric decompression. To prevent complications, the nurse should elevate the head of the bed, clamp the tube, use a small diameter suction catheter, or administer medications directly through the tube? The correct answer is A, elevate the head of the bed to at least 45 degrees. Elevating the head of the bed helps prevent reflux and aspiration in clients with a nasogastric tube.

A client is experiencing dyspnea and anxiety. What is the nurse's priority action? Administer a sedative medication?

Assess the client's oxygen? Encourage deep breathing exercise or provide a cold glass of water? A glass of cold water. The correct answer is B. Assess the client's oxygen saturation.

Assessing the client's oxygen saturation is the priority to determine the severity of their respiratory distress and guide appropriate interventions. A client is prescribed sub-q heparin for DVT prophylaxis. What is essential for the nurse to monitor in the client?

Blood pressure, respiratory rate, APTT, or serum potassium levels? The correct answer is activated partial thromboplasm time or APTT. Monitoring the APTT is essential to assess the therapeutic range and prevent complications in clients receiving heparin. A client has a wound that is healing by secondary intention.

The nurse understands that healing by secondary intention involves minimal tissue loss, epithelial cell migration, scar formation without granulation tissue, or wound edges brought together with sutures. The correct answer is B, epithelial cell migration. Healing by secondary intention involves the formation of granulation tissue and epithelial cell migration to fill the wound. as seen in open wounds with tissue loss.

The nurse is caring for a client who is immobile. To prevent complications, what intervention is most important for the nurse to implement? Encourage a high-protein diet.

Apply compression stockings, provide range of motion exercises, or elevate the client's legs? The correct answer is C, provide range of motion exercises. Range of motion exercises helps prevent complications of immobility, such as muscle atrophy and joint contractures.

A client with a history of heart failure is admitted to the hospital with acute decompensation. The nurse notes crackles in the lungs, jugular vein distension, and peripheral edema. The client is dyspneic and reports a weight gain of 5 pounds over the past two days. The nurse recognizes these findings as indicative of worsening heart failure.

What is the primary goal of initial management for a client with acute, decompensated heart failure experiencing fluid overload? The correct answer is A, administer loop diuretics to promote diuresis. By administering loop diuretics in this setting of acute decompensated heart failure with fluid overload, the primary goal of initial management is to reduce the fluid volume and relieve the symptoms. Loop diuretics such as furosemide are commonly used to promote diuresis and reduce excessive fluid retention.

Diuresis helps alleviate pulmonary congestion, which is crackles in the lungs, decrease JVD, jugular venous distension, and reduce peripheral edema. Loop diuretics acts on the loop of helpni in the kidneys, promoting the excretion of sodium and water. A client with type 1 diabetes is prescribed regular insulin and NPH insulin. The nurse should instruct the client to administer insulin in which order?

The correct answer is B, regular insulin followed by NPH insulin. The correct administration order for regular insulin, which is the short acting, and NPH, which is intermediate acting, is to draw up and administer the regular insulin first, followed by the NPH insulin. This sequence ensures that the rapid-active insulin is with hyperthyroidism. The nurse should assess the client for which common clinical manifestation? Bradycardia, weight gain, cold intolerance, or exoprothalamus?

The correct answer is D, exoprothalamus. Exoprothalamus or protruding eyeballs is a characteristic sign of hyperthyroidism, particularly in conditions like grave disease. Other manifestations of hyperthyroidism include tachycardia, weight loss, and heat intolerance.

A client with Addison's disease is at risk for adrenal crisis. The nurse should monitor for which critical sign of adrenal crisis? Hypertension, hyperglycemia, hypovolemia, or hypokalemia? The correct answer is C, hypovolemia. Adrenal crisis in clients with Addison's disease is characterized by severe hypovolemia, which can lead to hypotension, dehydration, and shock.

Prompt recognition and intervention are crucial to prevent life-threatening complications. A client with diabetes insipidus is prescribed desmopressin, acetate. The nurse should monitor the client for signs of hypoglycemia, fluid retention, hyperkalemia, or decreased urine output.

The correct answer is B, fluid retention. Desmopressin acetate is a synthetic form of ADH used to treat diabetes insipidus. ADH, when I say ADH, I mean antithyroidic hormone.

It promotes water reabsorption in the kidneys, leading to fluid retention. Monitoring for signs of hyponatremia and fluid overload is important during therapy. A client with hypothyroidism is prescribed levothyroxine. The nurse should instruct the client to take the medication with meals, on an empty stomach in the morning, before bedtime, or concurrently with calcium supplements. The correct answer is B, on an empty stomach in the morning.

Levothyroxine absorption is optimal when taken on an empty stomach, preferably in the morning. It should be taken at least 30 minutes before eating or taken other medications to ensure proper absorption. Concurrent administration with calcium supplements can interfere with absorption.

A client with Cushion syndrome is at risk for developing osteoporosis due to long-term exposure to excess cortisol. The nurse should recommend which intervention to mitigate this risk. Encourage weight-bearing exercises, limit vitamin D intake, promote a low-calcium diet, or restrict fluid intake. The correct answer is A, encourage weight-bearing exercises.

Weight-bearing exercises such as walking or resistance training can help mitigate the risk of osteoporosis in clients with Cushing syndrome. Adequate calcium and vitamin D intake are also important for bone health. A client is diagnosed with hyperparathyroidism.

The nurse should assess the client for which electrolyte imbalance commonly associated with this condition. Hyperkalemia, hypocalcemia, hyponatremia, or hypophosphatemia. The correct answer is B, hypocalcemia. Hyperparathyroidism can lead to increased release of parathyroid hormone.

resulted in elevated calcium levels and hypocalcemia. Clients may experience symptoms such as muscle cramps, tingling, and spasms. A client with pheochromocytoma is admitted to the hospital.

The nurse should assess the client for which characteristic signs and symptoms of this condition. The correct answer is A, hypertension, diaphoresis, and palpitations. Pheochromocytoma is characterized by the overproduction of catecholamines, leading to symptoms such as severe hypertension, diaphoresis, palpitations, and headaches. A client in the ICU has a central venous catheter in place.

The nurse notes redness, swelling, warmth at the insertion site. The client's temperature is elevated. What is the priority nurse in action? The correct answer is C.

remove the central venous catheter. The client's symptoms include redness, swelling, and warmth, and an elevated temperature at the central venous catheter site, which suggests a possible infection. The priority action is to remove the catheter to prevent further systemic infection and complications. A client in respiratory distress is admitted to the ER. The nurse auscultates wheezing, observes the use of accessory muscles, and notes a decreased level of consciousness.

What is the initial nursing intervention? The correct answer is A, administer oxygen therapy. The initial priority in respiratory distress is to ensure adequate oxygenation. Administering oxygen therapy is the first step to improve oxygen saturation.

Further interventions such as bronchodilators or endotracheal intubation may be necessary based on the client's response. A client in the CCU is monitored for dysrhythmias. The nurse observes a sudden onset of irregular chaotic heartbeats on the cardiac monitor.

The client is unresponsive. What is the immediate nursing action? The correct answer is A, begin chest compressions. The sudden onset of irregular chaotic heartbeats, ventricular fib, Requires the immediate initiation of CPR with chest compressions. This is a life-threatening dysrhythmia and prompt intervention is crucial.

A client with a neurological intensive care unit has increased intracranial pressure. The nurse should prioritize which intervention to reduce ICP. The correct answer is B.

Administer hypertonic saline. Hypertonic saline is often used to reduce intracranial pressure by drawing fluid out of the brain cells. Elevating the head of the bed, coughing, and deep breathing may be beneficial, but administering hypertonic saline is the priority.

A postoperative surgical client in the post-anesthesia unit is receiving intravenous opioids for pain control. The nurse observes the client's respiratory rate decreasing to 8. breaths per minute. What is the initial nursing action? Administer naloxone, increase the opioid infusion rate, assess the client's pain level, or D, apply oxygen via nasal cannula. A significant decrease in respiratory rate following opioid administration may indicate opioid overdose, so the correct answer is A, administer naloxone.

The initial action is to administer naloxone, an opioid antagonist, to reverse the effects of the opioid and restore adequate ventilation. A client in the ICU is receiving a continuous IV infusion, intravenous infusion, of a vasoactive medication to maintain blood pressure. The nurse notes a sudden drop in blood pressure and an increase in heart rate. What is the priority nursing action? The correct answer is C, notify the healthcare provider immediately.

A sudden drop in blood pressure and an increase in heart rate may indicate a potential adverse reaction to the vasoactive medication. The priority action is to notify the healthcare provider for further assessment and guidance. A client with acute respiratory distress syndrome is receiving mechanical ventilation. The nurse observes a decrease in breath sounds on one side.

and the chest tube on that side appears hyperresonant. What is the priority nursing action? The correct answer is D, notify the healthcare provider immediately. A decrease in breath sounds on one side and hyperresonance may indicate a pneumothorax, a potentially life-threatening complication. The priority action is to notify the healthcare provider for prompt evaluation and intervention.

A client in the neurological intensive care unit has a Glasgow Coma Scale score of 8. The nurse should prioritize which intervention? The correct answer is A, assess the pupillary response. A GCS score of 8 indicates a decreased level of consciousness.

Assessing pupillary response is a critical nursing intervention to monitor neurological status. Changes in pupillary size or reactivity can provide important information about the client's condition. A client admitted to the MedSurg ICU is at risk for developing acute respiratory distress syndrome. The nurse should identify which condition as a common risk factor for ARDS.

The correct answer is C, sepsis. Sepsis is a common risk factor for the development of ARDS. Other risk factors may include trauma, pneumonia, and aspiration of gastric contents.

Early recognition and management of sepsis are crucial in preventing ARDS. A client with chronic renal failure is prescribed a low-protein diet. The nurse should educate the client about the importance of restricting which specific nutrient.

The correct answer is D, phosphorus. In chronic renal failure, there is impaired excretion of phosphorus, leading to hyperphosphatemia. Restricting dietary phosphorus is crucial to manage the condition and prevent complications such as bone and mineral disorders.

A client is admitted with suspected acute pancreatitis. The nurse should monitor the client for which classic sign of this condition. The correct answer is C, jaundice. Jaundice is a classic sign of acute pancreatitis, indicating obstruction of the common bile duct due to inflammation. Other common signs include severe abdominal pain, nausea, and vomiting.

A client with heart failure is prescribed furosemide. The nurse should monitor the client for which potential electrolyte imbalance is associated with this medication. The correct answer is D, hypomagnesemia. Furosemide is a loop diuretic that can lead to the loss of magnesium resulting in hypomagnesemia. The nurse should monitor magnesium levels and educate the client about magnesium-rich foods.

A client with diabetes mellitus is admitted with a foot ulcer. The nurse should prioritize which intervention to promote wound healing. The correct answer is D, maintaining strict blood glucose control. Strike blood glucose control is crucial for promoting wound healing in clients with diabetes mellitus.

Elevated blood glucose levels can impair the healing process and increase the risk of infection. Controlling blood glucose helps optimize conditions for tissue repair. A client is admitted with a suspected gastrointestinal bleed. The nurse observes black tarry stools. What is the priority nursing action?

The correct answer is A. Obtain a stool sample for cold blood testing. Black tarry stools, melina, can indicate gastrointestinal bleeding. The priority action is to obtain a stool sample for cold blood testing to confirm the presence of blood and determine the source of bleeding. A client is scheduled for surgery to remove a thyroid tumor.

The nurse should assess the client for signs and symptoms of which potential complication. The correct answer is C, hypocalcemia. Surgical removal of the thyroid gland poses a risk of damaging the parathyroid glands, leading to hypocalcemia.

The nurse should monitor for signs of hypocalcemia such as tetany, numbness and tingling and collaborate with a healthcare provider for calcium supplements if needed. A client with rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which potential side effect of this medication. The correct answer is B, liver toxicity.

Methotrexate commonly used to treat rheumatoid arthritis can cause liver toxicity. The nurse should monitor liver function regularly and educate the client about signs of liver dysfunction such as jaundice and abdominal pain. A pregnant client is at 32 weeks gestation and reports abdominal pain. The nurse notes uterine contractions on a monitor.

What is the priority nurse in action? The correct answer is B. Place the client in a left lateral position. Placing the client in a left lateral position helps optimize uterine perfusion and is a priority intervention when uterine contractions are noted, especially in the third trimester. This position improves blood flow to the placenta and reduces pressure on the vena cava.

The nurse is planning a health promotion program for a community. Which strategy is most effective in promoting behavior change? The correct answer is B. B. Conducting community workshops and demonstrations.

Conducting community workshops and demonstrations is a more interactive and engaging strategy, promoting active participation and better retention of health information. A client prescribed Coumadin for DVT. The nurse should instruct the client about the importance of... The correct answer is C.

Consistent intake of foods high in vitamin K. Warfarin interacts with vitamin K and consistent intake of foods high in vitamin K help maintain the stability of the medication. Clients should not avoid vitamin K but rather consume a consistent amount to maintain the therapeutic effects of warfarin.

A client is admitted with severe dehydration. The nurse is planning care and knows that a priority intervention is to? The correct answer is C.

Assess Skin Turgor and Mucus Membranes. Assessing Skin Turgor and Mucus Membranes provides valuable information about the degree of dehydration. This initial assessment helps determine the severity of dehydration and guides subsequent interventions. A client with COPD is prescribed a bronchodilator therapy.

The nurse should instruct the client to use the bronchodilator. The correct answer is B. Daily at the same time each morning.

Bronchodilators for COPD are often prescribed on a scheduled basis to maintain bronchodilation and improve airflow. Using the medication daily at the same time helps establish your routine and optimize its effectiveness. The nurse is participating in a multidisciplinary team meeting.

What is the primary purpose of a multidisciplinary team? in a healthcare setting? The correct answer is B, problem solving and decision making. The primary purpose of multidisciplinary team in healthcare is to bring together individuals with different expertise to collaborate to solve problems and make decisions that benefit patient care.

A community health nurse is conducting a needs assessment for a specific population. Which step? should a nurse take first in the assessment process? The correct answer is C, define the target population. Defining the target population is the initial step in a needs assessment.

This step helps focus the assessment on the specific group that will benefit from the community health intervention. A client with depression is prescribed a SSRI. The nurse should educate the client about the need to monitor for... The correct answer is C, suicidal ideation.

SSRIs are commonly prescribed for depression, and the client should be monitored for the emergence of suicidal ideation, especially in the initial weeks of treatment. The nurse should instruct the client to report any changes in mood or thoughts immediately. A client is admitted with a suspected MI.

The nurse should assess the client for which classic symptom of MI? The correct answer is D, crushing substernal chest pain. The classic symptom of MI or heart attack is crushing substernal chest pain that may radiate to the left arm or jaw. This type of chest pain is often described as intense and pressure-like.

A client with schizophrenia is prescribed risperidone. The nurse should educate the client about the potential effect of the correct answer is A, weight gain. Weight gain is a potential side effect of risperidone, an atypical antipsychotic.

The nurse should educate the client about the importance of monitoring weight gain and adopting a healthy lifestyle. A client with respiratory infection is placed on contact precautions. What is the most appropriate personal protective equipment for the nurse to wear when entering the client's room? The correct answer is A, gown and gloves.

Contact precautions require the use of gown and gloves to prevent the transmission of infectious agents. Additional PPE such as mask and goggles may be needed based on the specific situation, but gowns and gloves are the minimum requirement. A client is admitted with a diagnosis of pneumonia.

The nurse is assessing the client's respiratory status. Which finding requires immediate intervention? The correct answer is D, inspiratory crackles heard on auscultation. Inspiratory crackles suggest fluid in the alveoli or bronchioles and may indicate a worsening respiratory status.

Immediate intervention is needed to address potential respiratory distress. A nurse is caring for a client with a new tracheostomy. What is the priority nursing action to maintain airway patency? The correct answer is A, suctioning the tracheostomy tube every four hours.

Regular suctioning of the tracheostomy tube is essential to maintain airway patency and prevent the accumulation of secretions. This helps ensure effective breathing for the client with a tracheostomy. A pregnant client is at 28 weeks gestation and reports sudden severe abdominal pain. The nurse notes vaginal bleeding and signs of shock.

What is the priority nursing action? The correct answer is C, preparing for an emergency C-section. The sudden onset of severe abdominal pain, vaginal bleeding, and signs of shock are indicative of a potential abrupt geoplacenta.

This is a medical emergency and the priority nursing action is to prepare for an emergency cesarean section to deliver the fetus promptly and address the maternal and fetal distress. Immediate intervention is essential to optimize outcomes for both the mother and the baby. Thank you for tuning in to MedNurse Farm.

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Transcript for:HESI Exit Exam Key Topics Review

Transcript for:
HESI Exit Exam Key Topics Review