2020 HESI EXIT V4
1. Parents of a 7 year-old child call the clinic nurse because their daughter was sent home
from school because of a rash. The child
... [Show More] had been seen the day before by the healthcare
provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most
appropriate action by the nurse?
A) Tell the parents to bring the child to the clinic for further evaluation
B) Refer the school officials to printed materials about this viral illness
C) Inform the teacher that the child is receiving antibiotics for the rash
D) Explain that this rash is not contagious and does not require isolation
The correct answer is D: Explain that this rash is not contagious and does not require
isolation
2. When making a home visit to a client with chronic pyelonephritis, which nursing
action has the highest priority?
A) Follow-up on lab values before the visit
B) Observe client findings for the effectiveness of antibiotics
C) Ask for a log of urinary output
D) As for the log of the oral intake
The correct answer is C: Ask for a log of urinary output
3. The nurse is caring for a newborn who has just been diagnosed with hypospadias.
After discussing the defect with the parents, the nurse should expect that
A) Circumcision can be performed at any time
B) Initial repair is delayed until ages 6-8
C) Post-operative appearance will be normal
D) Surgery will be performed in stages
The correct answer is D: Surgery will be performed in stages
4. The nurse is assessing a client on admission to a community mental health center.
The client discloses that she has been thinking about ending her life. The nurse's
best response would be
A) "Do you want to discuss this with your pastor?"
B) "We will help you deal with those thoughts."
C) "Is your life so terrible that you want to end it?"
D) "Have you thought about how you would do it?"
The correct answer is D: "Have you thought about how you would do it?"5. The nursing care plan for a client with decreased adrenal function should include
A) Encouraging activity
B) Placing client in reverse isolation
C) Limiting visitors
D) Measures to prevent constipation
The correct answer is C: Limiting visitors
6. The nurse is caring for a client with acute pancreatitis. After pain management,
which intervention should be included in the plan of care?
A) Cough and deep breathe every 2 hours
B) Place the client in contact isolation
C) Provide a diet high in protein
D) Institute seizure precautions
The correct answer is A: Cough and deep breathe every 2 hours
7. Which of the following conditions assessed by the nurse would contraindicate the
use of benztropine (Cogentin)?
A) Neuromalignant syndrome
B) Acute extrapyramidal syndrome
C) Glaucoma, prostatic hypertrophy
D) Parkinson's disease, atypical tremors
The correct answer is C: Glaucoma, prostatic hypertrophy
8. The nurse is caring for a client in the coronary care unit. The display on the cardiac
monitor indicates ventricular fibrillation. What should the nurse do first?
A) Perform defibrillation
B) Administer epinephrine as ordered
C) Assess for presence of pulse
D) Institute CPR
The correct answer is C: Assess for presence of pulse
9. During the use of an interpreter to teach a client about a procedure to do in the home
the nurse should take which approach?
A) Speak directly to the interpreter while presenting information and use pauses for
questions
B) Talk to the interpreter in advance and leave the client and interpreter aloneC) Include a family member and direct communications to that person
D) Face the client while presenting the information as the interpreter talks in the native
language
The correct answer is D: Face the client while presenting the information as theinterpreter
talks in the native language .
10. A client is in her third month of her first pregnancy. During the interview, she tells
the nurse that she has several sex partners and is unsure of the identity of the
baby's father. Which of the following nursing interventions is a priority?
A) Counsel the woman to consent to HIV screening
B) Perform tests for sexually transmitted diseases
C) Discuss her high risk for cervical cancer
D) Refer the client to a family planning clinic
The correct answer is A: Counsel the woman to consent to HIV screening
11. A client is discharged following hospitalization for congestive heart failure. The
nurse teaching the family suggests they encourage the client to rest frequently in
which ofthe following positions?
A) High Fowler's
B) Supine
C) Left lateral
D) Low Fowler's
The correct answer is A: High Fowler''s
12. A nurse who is evaluating a mentally retarded 2 year-old in a clinic should stress
which goal when talking to the child's mother?
A) Teaching the child self care skills
B) Preparing for independent toielting
C) Promoting the child's optimal development
D) Helping the family decide on long term care
The correct answer is C: Promoting the child''s optimal development
13. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist
the client with nutrition needs, the nurse should
A) Offer small meals of high calorie soft food
B) Assist the client to sit in a chair for meals
C) Provide additional servings of fruits and raw vegetables
D) Encourage the client to eat fish, liver and chicken
The correct answer is A: Offer small meals of high calorie soft food14. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital
heart disease. Which of these is most likely to be seen with this diagnosis?
A) Several otitis media episodes in the last year
B) Weight and height in 10th percentile since birth
C) Takes frequent rest periods while playing
D) Changing food preferences and dislikes
The correct answer is C: Takes frequent rest periods while playing
15. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment
parameter that will indicate that the child has adequate fluid replacement is
A) Urinary output of 30 ml per hour
B) No complaints of thirst
C) Increased hematocrit
D) Good skin turgor around burn
The correct answer is A: Urinary output of 30 ml per hour
16. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth
have chalky white-to-yellowish staining with pitting of the enamel. Which of the
following conditions would most
likely explain these findings?
A) Ingestion of tetracycline
B) Excessive fluoride intake
C) Oral iron therapy
D) Poor dental hygiene
The correct answer is B: Excessive fluoride intake
17. The nurse is reassigned to work at the Poison Control Center telephone hotline. In
which of these cases of childhood poisoning would the nurse suggest that parents
have the child drink orange juice?
A) An 18 month-old who ate an undetermined amount of crystal drain cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of
diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
The correct answer is A: An 18 month-old who ate an undetermined amount of crystal
drain cleaner18. Which of these is an example of a variation in the newborn resulting from the
presence of maternal hormones?
A) Engorgement of the breasts
B) Mongolian spots
C) Edema of the scrotum
D) Lanugo
The correct answer is A: Engorgement of the breasts
19. A 2 month-old child has had a cleft lip repair. The selection of which restraint would
require no further action by the charge nurse?
A) Elbow
B) Mummy
C) Jacket
D) Clove hitch
The correct answer is A: Elbow
20. A client treated for depression tells the nurse at the mental health clinic that he
recently purchased a handgun because he is thinking about suicide. The first
nursingaction should be to
A) Notify the health care provider immediately
B) Suggest in-patient psychiatric care
C) Respect the client's confidential disclosure
D) Phone the family to warn them of the risk
The correct answer is A: Notify the health care provider immediately
21. A client has just been admitted with portal hypertension. Which nursing [Show Less]