2020 HESI EXIT V5 Completed A++++
2020 HESI EXIT V5
1. A client comes into the community health center upset and crying stating “I will die
of
... [Show More] cancer now that I have this disease.” And then the client hands the nurse a paper
with one word written on it:
"Pheochromocytoma." Which response should the nurse state initially?
A) Pheochromocytomas usually aren't cancerous (malignant). But they may be associated
with cancerous tumors in other endocrine glands such as the thyroid (medullary
carcinoma of the thyroid).
B) This problem is diagnosed by blood and urine tests that reveal elevated levels of
adrenaline and noradrenaline.
C) Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to
detect an adrenal tumor.
D) You probably have had episodes of sweating, heart pounding and headaches.
The correct answer is A: Pheochromocytomas usually aren''t cancerous (malignant). But
they may be associated with cancerous tumors in other endocrine glands such as the
thyroid (medullary carcinoma of the thyroid).
2. A client with chronic congestive heart failure should be instructed to contact the
home health nurse if which finding occurs?
A) Weight gain of 2 pounds or more in a 48 hour period
B) Urinating 4 to 5 times each day
C) A significant decrease in appetite
D) Appearance of non-pitting ankle edema
The correct answer is A: Weight gain of 2 pounds or more in a 48 hour period
3. The nurse is caring for a client on mechanical ventilation. When performing
endotracheal suctioning, the nurse will avoid hypoxia by
A) Inserting a fenestrated catheter with a whistle tip without suction
B) Completing suction pass in 30 seconds with pressure of 150 mm Hg
C) Hyper oxygenating with 100% O2 for 1 to 2 minutes before and after each suction
pass
D) Minimizing suction pass to 60 seconds while slowly rotating the lubricated catheter
The correct answer is C: Hyper oxygenating with 100% O2 for 1-2 minutes before and
after each suction pass
4. A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of
dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary
nursing action with the focus of comfort should be to
A) Suggest 3 to 4 warm sitz baths per day
B) Cleanse the genitalia twice a day with soap and water
C) Spray warm water over genitalia after urination
D) Apply heat or cold to lesions as desired
The correct answer is A: Encourage 3 to 4 warm sitz baths per day5. Which finding would be the most characteristic of an acute episode of reactive
airway disease?
A) Auditory gurgling
B) Inspiratory laryngeal stridor
C) Auditory expiratory wheezing
D) Frequent dry coughing
The correct answer is C: Wheezing on expiration
6. Which tasks, if delegated by the new charge nurse to a unlicensed assistive
personnel (UAP), would require intervention by the nurse manager?
A) To help an elderly client to the bathroom.
B) To empty a foley catheter bag.
C) To bathe a woman with internal radon seeds.
D) To feed a 2 year-old with a broken arm.
The correct answer is C: To bathe a woman with internal radon seeds.
7. An 82 year-old client is prescribed eye drops for treatment of glaucoma. What
assessment is needed before the nurse begins teaching proper administration of themedication?
A) Determine third party payment plan for this treatment
B) The client‟s manual dexterity
C) Proximity to health care services
D) Ability to use visual assistive devices
The correct answer is B: The client‟s manual dexterity
8. The nurse uses the DRG (Diagnosis Related Group) manual to
A) Classify nursing diagnoses from the client's health history
B) Identify findings related to a medical diagnosis
C) Determine reimbursement for a medical diagnosis
D) Implement nursing care based on case management protocol
The correct answer is C: Determine reimbursement for a medical diagnosis
9. The community health nurse has been following the care for an adolescent with a
history of morbid obesity, asthma, hypertension and is 22 weeks in to a pregnancy.
Whichof these lab reports sent to the clinic need to be called to the teens health care
provider within the next hour?
A) Hemoblobin 11 g/L and calcium 6 mg/dl
B) Magnesium 0.8 mEq/L and creatinine 3 mg/dl
C) Blood urea nitrogen 28 and glucose 225 mg/dl
D) Hematocrit 33% and platelets 200,000
The correct answer is B: Magnesium 0.8 mEq/L and creatinine 3 mg/dl10.The nurse has identified what appears to be ventricular tachycardia on the cardiac
monitor of a client being evaluated for possible myocardial infarction. The first action
thenurse would perform is to
A) Begin cardiopulmonary resuscitation
B) Prepare for immediate defibrillation
C) Notify the "Code" team and health care provider
D) Assess airway breathing and circulation
The correct answer is D: Assess airway breathing and circulation
11.To prevent keratitis in an unconscious client, the nurse should apply
moisturizingointment to the
A) Finger and toenail quicks
B) Eyes
C) Perianal area
D) External ear canals
The correct answer is B: Eyes
12.The nurse is caring for a child with cystic fibrosis. The nurse would anticipate
thatthe child would be deficient in which vitamins?
A) B, D, and K
B) A, D, and K
C) A, C, and D
D) A, B, and C
The correct answer is B: A, D, and K
13.The nurse is teaching a 27 year-old client with asthma about management of their
therapeutic regime. Which statement would indicate the need for additional
instruction?
A) "I should monitor my peak flow every day."
B) "I should contact the clinic if I am using my medication more often."
C) "I need to limit my exercise, especially activities such as walking and running."
D) "I should learn stress reduction and relaxation techniques."
The correct answer is C: "I need to limit my exercise, especially activities such as
walking and running."
14.While caring for a child with Reye's Syndrome, the nurse should give which
actionthe highest priority?
A) Monitor intake and output
B) Provide good skin care
C) Assess level of consciousnessD) Assist with range of motion
The correct answer is C: Assess level of consciousness
15.A newborn presents with a pronounced cephalic hematoma following a birth in
theposterior position. Which nursing diagnosis should guide the plan of care?
A) Pain related to periosteal injury [Show Less]