HESI EXIT V 2

HESI EXIT V 2

• The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which

nursing intervention is appropriate for this child?

• Make certain the child is maintained in correct body alignment.
• Be sure the traction weights touch the end of the bed.
• Adjust the head and foot of the bed for the child's comfort D) Release the traction for

15-20 minutes every 6 hours PRN.

• The nurse is assessing a healthy child at the 2 year check up. Which of the following

should the nurse report immediately to the health care provider?

• Height and weight percentiles vary widely
• Growth pattern appears to have slowed
• Recumbent and standing height are different
• Short term weight changes are uneven
• The parents of a 2 year-old child report that he has been holding his breath

whenever he has temper tantrums. What is the best action by the nurse? A) Teach the parents how to perform cardiopulmonary resuscitation

• Recommend that the parents give in when he holds his breath to prevent anoxia
• Advise the parents to ignore breath holding because breathing will begin as a reflex
• Instruct the parents on how to reason with the child about possible harmful effects
• The nurse is assessing a client in the emergency room. Which statement suggests that

the problem is acute angina?

• "My pain is deep in my chest behind my sternum."
• "When I sit up the pain gets worse."
• "As I take a deep breath the pain gets worse."
• "The pain is right here in my stomach area."

.

• The nurse is assessing the mental status of a client admitted with possible organic brain

disorder. Which of these questions will best assess the function of the client's recent memory?

• "Name the year." "What season is this?" (pause for answer after each question)
• "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now

continue to subtract 7 from the new number."

• "I am going to say the names of three things and I want you to repeat them after

me: blue, ball, pen."

• "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose

of it?"

• In planning care for a 6 month-old infant, what must the nurse provide to assist in the

development of trust?

• Food
• Warmth
• Security
• Comfort
• A nurse has just received a medication order which is not legible. Which statement best

reflects assertive communication?

• "I cannot give this medication as it is written. I have no idea of what you mean."
• "Would you please clarify what you have written so I am sure I am reading it

correctly?"

• "I am having difficulty reading your handwriting. It would save me time if you

would be more careful."

• "Please print in the future so I do not have to spend extra time attempting to read

your writing."

• What is the most important consideration when teaching parents how to reduce risks

in the home?

• Age and knowledge level of the parents
• Proximity to emergency services
• Number of children in the home
• Age of children in the home
• A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the

nurse enters the room to request something for pain. The nurse should

• Administer a placebo
• Encourage increased fluid intake
• Administer the prescribed analgesia
• Recommend relaxation exercises for pain control
• While caring for a toddler with croup, which initial sign of croup requires the nurse's

immediate attention? A) Respiratory rate of 42

• Lethargy for the past hour
• Apical pulse of 54
• Coughing up copious secretions

• A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial

assessment, the nurse would anticipate which of the following assessment findings?

• Lethargy
• Heat intolerance
• Diarrhea
• Skin eruptions
• The emergency room nurse admits a child who experienced a seizure at school. The

father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse?

• "Do not worry. Epilepsy can be treated with medications."
• "The seizure may or may not mean your child has epilepsy."
• "Since this was the first convulsion, it may not happen again."
• "Long term treatment will prevent future seizures."
• Alcohol and drug abuse impairs judgment and increases risk taking behavior.

What nursing diagnosis best applies? A) Risk for injury

• Risk for knowledge deficit
• Altered thought process
• Disturbance in self-esteem
• The nurse is caring for a 10 month-old infant who is has oxygen via mask. It is

important for the nurse to maintain patency of which of these areas?

• Mouth
• Nasal passages
• Back of throat
• Bronchials
• The nurse is providing instructions for a client with pneumonia. What is the

most important information to convey to the client? A) "Take at least 2 weeks off from work."

• "You will need another chest x-ray in 6 weeks."
• "Take your temperature every day."
• "Complete all of the antibiotic even if your findings decrease."
• When counseling a 6 year old who is experiencing enuresis, what must the nurse

understand about the pathophysiological basis of this disorder?

• Has no clear etiology
• May be associated with sleep phobia

• Has a definite genetic link
• Is a sign of willful misbehavior
• The nurse is discussing negativism with the parents of a 30 month-old child. How

should the nurse tell the parents to best respond to this behavior?

• Reprimand the child and give a 15 minute "time out"
• Maintain a permissive attitude for this behavior
• Use patience and a sense of humor to deal with this behavior
• Assert authority over the child through limit setting
• The nurse is talking by telephone with a parent of a 4 year-old child who has

chickenpox. Which of the following demonstrates appropriate teaching by the nurse?

• Chewable aspirin is the preferred analgesic
• Topical cortisone ointment relieves itching
• Papules, vesicles, and crusts will be present at one time
• The illness is only contagious prior to lesion eruption
• The nurse is assigned to a client who has heart failure. During the morning rounds

the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally.Which nursing intervention should be performed first?

• Take the client's vital signs
• Place the client in a sitting position with legs dangling
• Contact the health care provider
• Administer the PRN anti-anxiety agent
• The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the

parents to

• Dress the child warmly to avoid chilling
• Keep the child away from other children for the duration of the rash
• Clean the affected areas with tepid water and detergent
• Wrap the child's hand in mittens or socks to prevent scratching
• A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special

family gatherings?" Which initial response by the nurse would be best?

• "A recovering person has to be very careful not to lose control, therefore, confine

your drinking just at family gatherings."

• "At your next AA meeting discuss the possibility of limited drinking with your

sponsor."