2020 HESI EXIT V3
2020 HESI EXIT V3
1. When providing nursing measures to relieve a 102-degree Fahrenheit fever in toddler
with an infection, what is
... [Show More] the most effective intervention?
A) Use medications to lower the temperature set point
B) Apply extra layers of clothing to prevent shivering
C) Immerse the child in a tub containing cool water
D) Give a tepid sponge bath prior to giving an antipyretic
The correct answer is A: Use medications to lower the temperature set point
2. A child is sent to the school nurse by a teacher who has a written note that Fifth’s
disease is suspected. Which characteristic would the nurse expect to find?
A) Macule that rapidly progresses to papule and then vesicles
B) Erythema on the face, primarily on cheeks giving a "slapped face" appearance
C) Discrete rose pink macules will appear first on the trunk and fade when pressure is
applied.
D) Kopeck spots appear first followed by a rash that appears first on the face and spreads
downward
The correct answer is B: Erythema on the face, primarily on cheeks giving a "slapped
face" appearance
3. Delirium tremens could best be described as
A) Disorganized thinking, feelings of terror and non-purposeful behavior
B) A generalized shaking of the body accompanied by repetitive thoughts
C) An excited state accompanied by disorientation, hallucination and tachycardia
D) Single or multiple jerks caused by rapid contracting muscles
The correct answer is C: An excited state accompanied by disorientation, hallucination
and tachycardia
4. An ambulatory client reports edema during the day in his feet and ankles that
disappears while sleeping at night. What is the most appropriate follow-up question for
the nurse to ask?
A) "Have you had a recent heart attack?"
B) "Do you become short of breath during your normal dailyactivities?"
C) "How many pillows do you use at night to sleep comfortably?"
D) "Do you smoke?"
The correct answer is B: "Do you become short of breath during your normal daily
activities?"
5. The nursing care plan for a toddler diagnosed with Kawasaki Disease
(mucocutaneous lymph node syndrome) should be based on the high risk for
development of which problem?A) Chronic vessel plaque formationB) Pulmonary embolism
C) Occlusions at the vessel bifurcations
D) Coronary artery aneurysms
The correct answer is D: Coronary artery aneurysms
6. The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old
client with a diagnosis of congestive heart disease. Which finding is most likely to occur?
A) Chest pain
B) Peripheral edema
C) Nail clubbing
D) Lethargy
The correct answer is B: Peripheral edema
7. While working with an obese adolescent, it is important for the nurse to recognize
that obesity in adolescents is most often associated with what other
behavior?
A) Sexual promiscuity
B) Poor body image
C) Dropping out of school
D) Drug experimentation
The correct answer is B: Poor body image
8. The nurse should initiate discharge planning for a client
A) When the client or family demonstrate readiness to learn self care modalities
B) When informed that a date for discharge has been determined
C) Upon admission to the emergency room
D) When the client's condition is stabilized on the assigned unit The correct answer is C:
Upon admission to the emergency room
9. The nurse is caring for a client with a pressure ulcer on the heel that is covered with
black hard tissue. Which would be an appropriate goal in planning care for this client?
A) Protection for the granulation tissue
B) Heal infection
C) Decried eschar
D) Keep the tissue intact
The correct answer is D: Keep the tissue intact
The correct answer is D: Carry the nitroglycerine with you at all times
10. 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 assistwith 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 timefor
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
11. 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."
12. 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
13. 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 amberalmost
brown color.
14. 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 tapeD) Assist the client with ambulation and a gown change
The correct answer is D: Assist the client with ambulation and a gown change
15. A practical nurse (PN) from the pediatric unit is assigned to work in a critical care
unit. Which client assignment would be appropriate?
A) A client admitted with multiple trauma with a history of a newly implanted pacemaker
B) A new admission with left-sided weakness from a stroke and mild confusion
C) A 53 year-old client diagnosed with cardiac arrest from a suspected myocardial
infarction
D) A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle
accident
The correct answer is D: A 35 year-old client in balanced traction admitted 6 days ago
after a motor vehicle accident
16. A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred
from the hospital to a long term care facility. To which o staff members should the charge
nurse assign the client?
A) Unlicensed assistive personnel (UAP)
B) Senior nursing student
C) PN
D) RN
The correct answer is D: An RN
17. Which statement by the nurse is appropriate when giving an assignment to an
unlicensed assistive personnel (UAP) to ambulate a client for the first time after a colon
resection?
A) "Have the client sit on the side of the bed before helping the client to walk."
B) "If the client is dizzy ask the client to take some slow, deep breaths."
C) "Help the client to walk in the room as often as the client wishes."
D) "When you help the client to walk, ask if any pain occurs."
The correct answer is A: "Have the client sit on the side of the bed before helping him/herto
walk."
18. A charge nurse working in a long term care facility is making out assignments. Which
assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires
intervention by the supervisor?
A) Provide decubitus ulcer care and apply a dry dressing
B) Bathe and feed a client on bed rest
C) Oral suctioning of an unresponsive elderly client
D) Teaching a family intermittent (bolus) feedings via G-tube before discharge
The correct answer is D: Teaching a family intermittent (bolus) feedings via G-tubebefore
discharge19. Which task for a client with anemia and confusion could the nurse delegate to the
unlicensed assistive personnel (UAP)?
A) Document skin turgor and color changes
B) Test stool for occult blood and urine for glucose
C) Suggest foods high in iron and those easily consumed
D) Report mental status changes and the degree of mental clarity
The correct answer is B: Test stool for occult blood and urine for glucose
20. Which one of these tasks can be safely delegated to a PN?
A) Assess the function of a newly created ileostomy
B) Care for a client with a recent complicated double barrel colostomy
C) Provide stoma care for a client with a well functioning ostomy
D) Teach ostomy care to a client and their family members
The correct answer is C: Provide stoma care for a client with a well functioning ostomy [Show Less]