Question

A male client reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mm Hg. Which risk factor(s) should the nurse explore further with the client? Select all that apply.

Answer 1

Correct Answers:

History of hypertension.
Family health history.

Rationale :

🔷 History of hypertension

Hypertension is a modifiable risk factor for cardiovascular events. Even if blood pressure is controlled with medication, the underlying condition still increases cardiac risk and warrants ongoing management and lifestyle counseling.

🔷 Family health history

Having first-degree relatives with heart disease and diabetes significantly elevates this client’s risk of developing cardiovascular issues. Genetics, especially in early-onset disease or multiple family members affected, plays a strong role in cardiac risk.

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Answer 2

Correct Answers:

Bring a sterile chest drainage unit from central supply to the unit.

Rationale :

🔶 UAPs may perform non-clinical support tasks such as retrieving equipment. Bringing a sterile chest drainage unit does not involve clinical decision-making or assessment, and falls within the UAP's scope.

🔶 Delegation requires understanding what can be safely assigned based on training and role boundaries—tasks involving evaluation, communication with licensed providers, or clinical judgment cannot be delegated to UAPs.

🔶 Observation and evaluation (like gait or catheter assessment) are considered nursing responsibilities because they require clinical judgment.

🔶 Delegating appropriately ensures client safety and efficient use of team roles in nursing care delivery.

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Answer 3

Correct Answers:

Maintain the client on an NPO status.

Rationale :

💠 NPO (nothing by mouth) status is necessary when a post-bariatric client presents with vomiting and intolerance to oral intake, as this may indicate gastric outlet obstruction, stomal stenosis, or early dumping syndrome. Holding oral intake prevents further gastric distention, aspiration risk, and irritation of the surgical site.

💠 Clients who have undergone bariatric surgery are vulnerable to mechanical and functional complications such as narrowing at the anastomosis site, necessitating temporary NPO status for evaluation.

💠 While nutritional support and psychological encouragement are crucial in the long term, the priority intervention is protecting the gastrointestinal tract and identifying the source of vomiting.

💠 The client being pain-free does not rule out obstruction or serious gastric dysfunction, hence fasting ensures safe stabilization until diagnostics are completed.

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Answer 4

Correct Answers:

Allow the client time to complete her sentence.

Rationale :

✝️Clients with aphasia often experience difficulty with word retrieval but can still understand what they want to say. Allowing time promotes independence and dignity, giving the client space to process and formulate speech without pressure.

✝️ Interrupting or completing sentences for clients may cause frustration or dependence and hinder speech therapy progress.

✝️ This approach encourages communication autonomy, reinforcing the therapeutic nurse-client relationship.

✝️ Silence can be therapeutic—used purposefully, it fosters trust and minimizes emotional stress in clients struggling with language.

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Answer 5

Correct Answers:

Document why the blood pressure cannot be accurately measured at the present time.

Rationale :

✝️ If blood pressure measurement is not possible using standard methods, the nurse must document the limitation and rationale. This ensures clear communication to the healthcare team and protects patient safety.

✝️In cases where arms and legs are inaccessible due to casts or positioning, alternate sites or timing may be needed, but estimation or delegation without reliable methods is inappropriate.

✝️ Accurate documentation promotes continuity of care and signals the need for reassessment or alternative monitoring (e.g., arterial line if needed).

✝️The nurse is responsible for clinical decision-making, including identifying when standard measurements cannot be obtained and ensuring that this is clearly communicated in the record.

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Answer 6

Correct Answers:

Hold the newborn in an upright position.

Rationale :

✝️ Feeding an infant with a cleft lip requires careful technique to prevent aspiration and ensure adequate nutrition. The most important positioning is upright to support swallowing and decrease the risk of nasal regurgitation or choking.

✝️Upright posture allows gravity to assist in moving milk downward and minimizes pressure around the oral cavity defect, especially with special nipples like those with valves or slits.

✝️Proper positioning also supports respiratory safety and gives the caregiver better control during the feed.

✝️Feeding should be slow, deliberate, and monitored closely, but forced expression or alternating liquids is not part of best practices for cleft-feeding.

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Answer 7

Correct Answers:

No Correct Answers Available !

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Answer 8

Correct Answers:

No Correct Answers Available !

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Answer 9

Correct Answers:

5.6

Rationale :

We solve this step-by-step using dimensional analysis:

Step 1: Convert weight to kg

132 lb × 0.45 = 59.4 kg

Step 2: Calculate dose per minute

5 mcg × 59.4 kg = 297 mcg/min

Step 3: Convert mcg to mg

297 mcg ÷ 1000 = 0.297 mg/min

Step 4: Determine concentration (from pharmacy)

1600 mg in 500 mL = 3.2 mg/mL

Step 5: Calculate infusion rate in mL/min

0.297 mg ÷ 3.2 mg/mL = 0.0928 mL/min

Step 6: Convert to mL/hour

0.0928 mL/min × 60 = 5.57 mL/hour, round to 5.6 mL/hr

📝 Takeaway Note:

Weight-based infusions require unit conversions and dimensional accuracy. Double-check the drug concentration provided by the pharmacy to match the dosage. Always round to the tenth for IV pump settings when instructed.

👩‍🏭 The most common answer in clinical references using standard 1600 mg/250 mL Dopamine solution for 132 lb weight (59.4 kg) at 5 mcg/kg/min is 7.5 mL/hr — indicating a possible different concentration or standard double-check scenario.

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Answer 10

Correct Answers:

No Correct Answers Available !

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RN HESI Exit~2025 Exam 1

No.

2 : Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

3 : A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

4 : A female client with aphasia is trying to verbalize feelings to the nurse and states, "I want ...." but does not finish the statement. How should the nurse respond to this unfinished statement?

5 : The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

8 : The nurse is preparing an older adult client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

📝 Takeaway Note:

10 : A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

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