2020 HESI EXIT V2
2020 HESI EXIT V2
1. The nurse is teaching parents about diet for a 4 month-old infantwith
gastroenteritis
and mild dehydration.
... [Show More] In addition to oral rehydration fluids, the dietshould include
A) Formula or breast milk
B) Broth and tea
C) Rice cereal and apple juice
D) Gelatin and ginger ale
The correct answer is A: Formula or breast milk
2. The nurse instructs the client taking dexamethasone (Decadron) totake it with
food
or milk. What is the physiological basis for this instruction?
A) Retards pepsin production
B) Stimulates hydrochloric acid production
C) Slows stomach emptying time
D) Decreases production of hydrochloric acid
The correct answer is B: Stimulates hydrochloric acid production
3. The nurse is planning care for a 3 month-old infant immediately
postoperative
following placement of a ventriculoperitoneal shunt for hydrocephalus.
The nurse needsto
A) Assess for abdominal distention
B) Maintain infant in an upright position
C) Begin formula feedings when infant is alert
D) Pump the shunt to assess for proper function
The correct answer is A: Assess for abdominal distention
4. The mother of a 2 year-old hospitalized child asks the nurse's adviceabout
the
child's screaming every time the mother gets ready to leave the hospitalroom. What
is the
best response by the nurse?
A) "I think you or your partner needs to stay with the child while in the
hospital."
B) "Oh, that behavior will stop in a few days."
C) "Keep in mind that for the age this is a normal response to being in the
hospital."
D) "You might want to "sneak out" of the room once the child falls asleep."The
correct answer is C: "Keep in mind that for the age this is a normal response to
being in the hospital."
5. When caring for a client receiving warfarin sodium (Coumadin),which
lab test
would the nurse monitor to determine therapeutic reponse to the drug?
A) Bleeding timeB) Coagulation time
C) Prothrombin time
D) Partial thromboplastin time
The correct answer is C: Prothrombin time
6. The nurse is caring for a 4 year-old 2 hours after tonsillectomy and
adenoidectomy.
Which of the following assessments must be reported immediately?
A) Vomiting of dark emesis
B) Complaints of throat pain
C) Apical heart rate of 110
D) Increased restlessness
The correct answer is D: Increased restlessness
7. The nurse admits a 7 year-old to the emergency room after a leginjury.
The x-rays
show a femur fracture near the epiphysis. The parents ask what will bethe
outcome of
this injury. The appropriate
response by the nurse should be which of these statements?
A) "The injury is expected to heal quickly because of thin periosteum."
B) "In some instances the result is a retarded bone growth."
C) "Bone growth is stimulated in the affected leg."
D) "This type of injury shows more rapid union than that of younger
children."
The correct answer is B: "In some instances the result is a retarded bonegrowth."
8. A client receiving chlorpromazine HCL (Thorazine) is in psychiatrichome
care.
During a home visit the nurse observes the client smacking her lipsalternately
with
grinding her teeth. The nurse
recognizes this assessment finding as what?
A) Dystonia
B) Akathesia
C) Brady dysknesia
D) Tardive dyskinesia
The correct answer is D: Tardive dyskinesia
9. During the check up of a 2 month-old infant at a well baby clinic, themother
expresses concern to the nurse because a flat pink birthmark on thebaby's
forehead and
eyelid has not gone away. What is an appropriate response by the nurse?
A) "Mongolian spots are a normal finding in dark-skinned children."
B) "Port wine stains are often associated with other malformations."
C) "Telangiectatic nevi are normal and will disappear as the baby grows."
D) "The child is too young for consideration of surgical removal of these atthis
time."The correct answer is C: Telangiectatic nevi are normal and will disappearas the
baby
Grows
10. A client has returned to the unit following a renal biopsy. Which ofthe
following
nursing interventions is appropriate?
A) Ambulate the client 4 hours after procedure
B) Maintain client on NPO status for 24 hours
C) Monitor vital signs
D) Change dressing every 8 hours
The correct answer is C: Monitor vital signs
11. A client has been admitted with a fractured femur and has beenplaced in
skeletal
traction. Which of the following nursing interventions should receivepriority?
A) Maintaining proper body alignment
B) Frequent neurovascular assessments of the affected leg
C) Inspection of pin sites for evidence of drainage or inflammation
D) Applying an over-bed trapeze to assist the client with movement in bedThe
correct answer is B: Frequent neurovascular assessments of the affected leg
12. The nurse is teaching a client newly diagnosed with asthma how touse the
metereddose
inhaler (MDI). The client asks when they will know the canister is empty.
The best
response is
A) Drop the canister in water to observe floating
B) Estimate how many doses are usually in the canister
C) Count the number of doses as the inhaler is used
D) Shake the canister to detect any fluid movement
The correct answer is A: Drop the canister in water to observe floating
13. While teaching the family of a child who will take phenytoin (Dilantin)
regularly for
seizure control, it is most important for the nurse to teach them aboutwhich of the
following actions?
A) Maintain good oral hygiene and dental care
B) Omit medication if the child is seizure free
C) Administer acetaminophen to promote sleep
D) Serve a diet that is high in iron
The correct answer is A: Maintain good oral hygiene and dental care
14. A 7 month pregnant woman is admitted with complaints of painlessvaginal
bleeding
over several hours. The nurse should prepare the client for an immediate
A) Non stress test
B) Abdominal ultrasoundC) Pelvic exam
D) X-ray of abdomen
The correct answer is B: Abdominal ultrasound
15. The nurse is assessing a 17 year-old female client with bulimia.
Which of the
following laboratory reports would the nurse anticipate?
A) Increased serum glucose
B) Decreased albumin
C) Decreased potassium
D) Increased sodium retention
The correct answer is C: Decreased potassium
16. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting,
abdominal
cramps and halo vision. Which of the following laboratory results shouldthe
nurse
analyze first?
A) Potassium levels
B) Blood pH
C) Magnesium levels
D) Blood urea nitrogen
The correct answer is A: Potassium levels
17. The nurse caring for a 9 year-old child with a fractured femur is toldthat a
medication error occurred. The child received twice the ordered dose ofmorphine
an
hour ago. Which nursing diagnosis is a priority at this time?
A) Risk for fluid volume deficit related to morphine overdose
B) Decreased gastrointestinal mobility related to mucosal irritation
C) Ineffective breathing patterns related to central nervous system
depression
D) Altered nutrition related to inability to control nausea and vomiting The
correct answer is C: Ineffective breathing patterns related to centralnervous system
Depression
18. The nurse notes that a 2 year-old child recovering from a
tonsillectomy has an
temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM thechild's
mother
reports that the child "feels very
warm" to touch. The first action by the nurse should be to
A) Reassure the mother that this is normal
B) Offer the child cold oral fluids
C) Reassess the child's temperature
D) Administer the prescribed acetaminophen
The correct answer is C: Reassess the child''s temperature19. The nurse is teaching a newly diagnosed asthma client on how touse a
peak flow
meter. The nurse explains that this should be used to
A) Determine oxygen saturation
B) Measure forced expiratory volume
C) Monitor atmosphere for presence of allergens
D) Provide metered doses for inhaled bronchodilator
The correct answer is B: Measure forced expiratory volume
20. The nurse is performing a pre-kindergarten physical on a 5 year old.
The last series
of vaccines will be administered. What is the preferred site for injection bythe nurse?
A) Vastus intermedius
B) Gluteus rainlinus
C) Vastus lateralis
D) DorsogluteaI
The correct answer is C: Vastus lateralis
21. A couple experienced the loss of a 7 month-old fetus. In planning for
discharge,
what should the nurse emphasize?
A) To discuss feelings with each other and use support persons
B) To focus on the other healthy children and move through the loss
C) To seek causes for the fetal death and come to some safe conclusion
D) To plan for another pregnancy within 2 years and maintain physicalhealth
The correct answer is A: To discuss feelings with each other and usesupport
persons
22. The parents of a 4 year-old hospitalized child tell the nurse, “We areleaving
now
and will be back at 6 PM.” A few hours later the child asks the nurse whenthe
parents
will come again. What is the best
response by the nurse?
A) "They will be back right after supper."
B) "In about 2 hours, you will see them."
C) "After you play awhile, they will be here."
D) "When the clock hands are on 6 and 12."
The correct answer is A: "They will be back right after supper."
23. The nurse is providing instructions for a client with asthma. Which ofthe
following
should the client monitor on a daily basis?
A) Respiratory rate
B) Peak air flow volumes
C) Pulse oximetry
D) Skin color
The correct answer is B: Peak air flow volumes24. Therapeutic nurse-client interaction occurs when the nurse
A) Assists the client to clarify the meaning of what the client has said
B) Interprets the client’s covert communication
C) Praises the client for appropriate feelings and behavior
D) Advises the client on ways to resolve problems
The correct answer is A: Assists the client to clarify the meaning of whatthe client
has said
25. A 14 month-old child ingested half a bottle of aspirin tablets. Whichof the
following
would the nurse expect to see in the child?
A) Hypothermia
B) Edema
C) Dyspnea
D) Epistaxis
The correct answer is D: Epistaxis
26. The nurse is caring for a client with a distal tibia fracture. The clienthas had a
closed reduction and application of a toe to groin cast. 36 hours aftersurgery, the
client
suddenly becomes confused, short of breath and spikes a temperature of103 degrees
Fahrenheit. The first assessment the nurse should perform is
A) Orientation to time, place and person
B) Pulse oximetry
C) Circulation to casted extremity
D) Blood pressure
The correct answer is B: Pulse oximetry
27. Which nursing intervention will be most effective in helping a
withdrawn client to
develop relationship skills?
A) Offer the client frequent opportunities to interact with 1 person
B) Provide the client with frequent opportunities to interact with otherclients
C) Assist the client to analyze the meaning of the withdrawn behavior
D) Discuss with the client the focus that other clients have similar
problems
The correct answer is A: Offer the client frequent opportunities to interactwith one
Person
28. The nurse is assessing a client with a Stage 2 skin ulcer. Which of the
following
treatments is most effective to promote healing?
A) Covering the wound with a dry dressing
B) Using hydrogen peroxide soaks
C) Leaving the area open to dry
D) Applying a hydrocolloid or foam dressing
The correct answer is D: Applying a hydrocolloid or foam dressing29. A female client is admitted for a breast biopsy. She says, tearfully tothe
nurse, "If
this turns out to be cancer and I have to have my breast removed, mypartner will
never
come near me." The nurse's best response would be which of thesestatements?
A) "I hear you saying that you have a fear for the loss of love."
B) "You sound concerned that your partner will reject you."
C) "Are you wondering about the effects on your sexuality?"
D) "Are you worried that the surgery will change you?"
The correct answer is D: "Are you worried that the surgery will changeyou?"
30. When teaching suicide prevention to the parents of a 15 year-oldwho
recently
attempted suicide, the nurse describes the following behavioral cue
A) Angry outbursts at significant others
B) Fear of being left alone
C) Giving away valued personal items
D) Experiencing the loss of a boyfriend
The correct answer is C: Giving away valued personal items
31. The nurse is caring for a 4 year-old admitted after receiving burns tomore
than 50%
of his body. Which laboratory data should be reviewed by the nurse as apriority
in the
first 24 hours?
A) Blood urea nitrogen
B) Hematocrit
C) Blood glucose
D) White blood count
The correct answer is A: Blood urea nitrogen
32. The nurse is assigned to care for a client who had a myocardial
infarction (MI) 2
days ago. The client has many questions about this condition. What areais a
priority for
the nurse to discuss at this time?
A) Daily needs and concerns
B) The overview cardiac rehabilitation
C) Medication and diet guideline
D) Activity and rest guidelines
The correct answer is A: Daily needs and concerns
33. The nurse is preparing a client with a deep vein thrombosis (DVT) fora
Venous
Doppler evaluation. Which of the following would be necessary forpreparing the
clientfor this test?
A) Client should be NPO after midnight
B) Client should receive a sedative medication prior to the test
C) Discontinue anti-coagulant therapy prior to the test
D) No special preparation is necessary
The correct answer is D: No special preparation is necessary
34. While interviewing a client, the nurse notices that the client isshifting
positions,
wringing her hands, and avoiding eye contact. It is important for thenurse to
A) Ask the client what she is feeling
B) Assess the client for auditory hallucinations
C) Recognize the behavior as a side effect of medication
D) Re-focus the discussion on a less anxiety provoking topicThe
correct answer is A: Ask the client what she is feeling
35. Which statement made by a client indicates to the nurse that hemay have
a thought
disorder?
A) "I'm so angry about this. Wait until my partner hears about this."
B) "I'm a little confused. What time is it?"
C) "I can't find my 'mesmer' shoes. Have you seen them?"
D) "I'm fine. It's my daughter who has the problem."
The correct answer is C: "I can''t find my ''mesmer'' shoes. Have you seenthem?"
36. The nurse is observing a client with an obsessive-compulsive
disorder in an inpatient
setting. Which behavior is consistent with this diagnosis?
A) Repeatedly checking that the door is locked
B) Verbalized suspicions about thefts
C) Preference for consistent care givers
D) Repetitive, involuntary movements
The correct answer is A: Repeatedly checking that the door is locked
37. A young adult seeks treatment in an outpatient mental health center.
The client tells
the nurse he is a government official being followed by spies. On further
questioning, he [Show Less]