HESI RN EXIT EXAM V3 FULL 160 QUESTIONS AND ANSWERS.

56. The nurse is caring for an 81 year-old client with colorectal cancer. The client's pain has been managed until now with acetaminophen with codeine. Because of increased pain, intravenous morphine is added. What should the nurse recognize about the validity of this order? A) Inappropriate because of potential respiratory depression B) Appropriate despite the expected effect of mental confusion C) Inappropriate and demonstrates poor knowledge of pain control D) Appropriate pain management around-the-clock The correct answer is D: Appropriate pain management around-the-clock 57. Before administering digoxin (Lanoxin) to a client, which of the following nursing assessments is a priority? A) Auscultate breath sounds B) Check for bowel sounds C) Monitor the heart rate D) Measure the blood pressure The correct answer is C: Monitor the heart rate 58. When teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that which of these is the most common side effect? A) Headache B) Dry mouth C) Depression D) Anorexia The correct answer is A: Headache 59. What would the nurse expect to see in a client who is experiencing symptoms of tardive dyskinesia? A) Rapid tongue movements B) Uncontrolled hand tremors during meals C) Behavioral changes D) Repetitive slapping movements The correct answer is A: Rapid tongue movements 60. The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which of the following must be emphasized? A) Rest in bed for an hour after taking medication B) Take the medication at the same time each day C) Keep the medication bottle in the refrigerator D) Carry the nitroglycerine with you at all times The correct answer is D: Carry the nitroglycerine with you at all times 61. The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? A) Ask the client and family if they are satisfied with the care given B) Determine if the home health aide's care is consistent with the plan of care C) Investigate if the home health aide is prompt and stays an appropriate length of time for care D) Check the documentation of the aide for appropriateness and comprehensiveness The correct answer is B: Determine if the home health aide is following the plan of care 62. The nurse in the same day surgery unit assigns the unlicensed assistive personnel (UAP) to give a 1000 ml soap solution enema (SSE) to a client scheduled for an abdominal hysterectomy. Which statement by the nurse is most appropriate? A) "Administer enemas until the results are clear." B) "Give 3 enemas before surgery." C) "Let me know the results of the enema." D) "Slow the flow of the solution if cramping occurs." The correct answer is D: "Slow the flow of the solution if cramping occurs." 63. An RN from the women’s health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse? A) A newly diagnosed client with type 2 diabetes mellitus who is learning foot care B) A client from a motor vehicle accident with an external fixation device on the leg C) A client admitted for a barium swallow after a transient ischemic attack D) A newly admitted client with a diagnosis of pancreatic cancer The correct answer is B: A motor vehicle accident (MVA) client with an external fixation device on the leg 64. Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items? A) The client has complaints of not sleeping well for the past week. B) The family wants to discontinue the home meal service, meals on wheels. C) The urine in the urinary catheter bag is of a deeper amber, almost brown color. D) The partner says the client has slower days every other day. The correct answer is C: The urine in the urinary catheter bag is of a deeper amber almost brown color. 65. A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)? A) Ask the client the degree of relief and document the client’s response B) Decrease the set rate on the pump by 2 ml/minute C) Check the IV site for drainage and loose tape D) Assist the client with ambulation and a gown change The correct answer is D: Assist the client with ambulation and a gown change