HESI Exit Exam V2 Latest
1. The LPN/LVN is preparing to ambulate a postoperative client after
cardiac surgery. The nurse plans to do which to enable the
... [Show More] client to
best tolerate the ambulation?
1. Provide the client with a walker.
2. Remove the telemetry equipment.
3. Encourage the client to cough and deep breathe.
4. Premedicate the client with an analgesic before ambulating.
2. A client is wearing a continuous cardiac monitor, which begins to alarm
at the nurse's station. The nurse sees no electrocardiographic
complexes on the screen. The nurse should do which first?
a. Call a code blue.
b. Call the health care provider.
c. Check the client status and lead placement.
d. Press the recorder button on the ECG console.
3. 3) The LPN/LVN in a medical unit is caring for a client with heart
failure. The client suddenly develops extreme dyspnea, tachycardia,
and lung crackles, and the nurse suspects pulmonary edema. The
nurse immediately notifies the registered nurse and expects which
interventions to be prescribed? Select all that apply.
a. Administering oxygen
b. Inserting a Foley catheter
c. Administering furosemide (Lasix)
d. Administering morphine sulfate intravenously
e. Transporting the client to the coronary care unit
f. Placing the client in a low-Fowler's side-lying position
4. The nurse is monitoring a client following cardioversion.
Which observations should be of highest priority to the nurse?
a. Blood pressure
b. Status of airway
c. Oxygen flow rate
d. Level of consciousness
5. The nurse is assisting in caring for the client immediately
after insertion of a permanent demand pacemaker via the rightpg. 2
subclavian vein. The nurse prevents dislodgement of the pacing
catheter by implementing which intervention?
a. Limiting movement and abduction of the left arm
b. Limiting movement and abduction of the right arm
c. Assisting the client to get out of bed and ambulate with a
walker 4. Having the physical therapist do active range of
motion to the right arm
6. A client diagnosed with thrombophlebitis 1 day ago suddenly
complains of chest pain and shortness of breath, and the client is
visibly anxious. The LPN/LVN understands that a life-threatening
complication of this condition is which?
a. Pneumonia
b. Pulmonary edema
c. Pulmonary embolism
d. Myocardial infarction
7. A 24-year-old man seeks medical attention for complaints of
claudication in the arch of the foot. The nurse also notes superficial
thrombophlebitis of the lower leg. The nurse should check the client
for which next?
a. Smoking history
b. Recent exposure to allergens
c. History of recent insect bites
d. Familial tendency toward peripheral vascular disease
8. The nurse has reinforced instructions to the client with
Raynaud's disease about self-management of the disease
process. The nurse determines that the client needs further
teaching if the client states which?
a. "Smoking cessation is very important."
b. "Moving to a warmer climate should help."
c. "Sources of caffeine should be eliminated from the diet."
4. "Taking nifedipine (Procardia) as prescribed will
decrease vessel spasm."
9. A client with myocardial infarction suddenly becomes tachycardic,
shows signs of air hunger, and begins coughing frothy, pinktinged sputum. The nurse listens to breath sounds, expecting to
hear which breath sounds bilaterally?
a. Rhonchi
b. Crackles
c. Wheezespg. 3
d. Diminished breath sounds
10. The LPN/LVN is collecting data on a client with a diagnosis of
right sided heart failure. The nurse should expect to note which
specific characteristic of this condition?
a. Dyspnea
b. Hacking cough
c. Dependent edema
d. Crackles on lung auscultation
11. The LPN/LVN is checking the neurovascular status of a client
who returned to the surgical nursing unit 4 hours ago after
undergoing an aortoiliac bypass graft. The affected leg is warm, and
the nurse notes redness and edema. The pedal pulse is palpable
and unchanged from admission. The nurse interprets that the
neurovascular status is which?
a. Moderately impaired, and the surgeon should be called
b. Normal, caused by increased blood flow through the leg
c. Slightly deteriorating, and should be monitored for another
hour
d. Adequate from an arterial approach, but venous
complications are arising
12. A client with a diagnosis of rapid rate atrial fibrillation asks the
nurse why the health care provider is going to perform carotid
massage. The LPN/LVN responds that this procedure may stimulate
which?
a. Vagus nerve to slow the heart rate
b. Vagus nerve to increase the heart rate
c. Diaphragmatic nerve to slow the heart rate
d. Diaphragmatic nerve to increase the heart rate
13. A client is admitted to the hospital with possible rheumatic
endocarditis. The LPN/LVN should check for a history of which type
of infection?
a. Viral infection
b. Yeast infection
c. Streptococcal infection
d. Staphylococcal infection
14. A client has an Unna boot applied for treatment of a venous
stasis leg ulcer. The LPN/LVN notes that the client's toes are mottled,pg. 4
and cool and the client verbalizes some numbness and tingling of the
foot. Which interpretation should the nurse make of these findings?
a. The boot has not yet dried.
b. The boot is controlling leg edema.
c. The boot is impairing venous return.
d. The boot has been applied too tightly.
15. A client with angina complains that the anginal pain is
prolonged and severe and occurs at the same time each day, most
often in the morning. On further data collection, the nurse notes that
the pain occurs in the absence of precipitating factors. How should
the LPN/LVN best describe this type of anginal pain?
a. Stable angina
b. Variant angina
c. Unstable angina
d. Nonanginal pain
16. The LPN/LVN is monitoring a client with an abdominal
aortic aneurysm (AAA). Which finding is probably unrelated to
the AAA?
a. Pulsatile abdominal mass
b. Hyperactive bowel sounds in the area
c. Systolic bruit over the area of the mass
d. Subjective sensation of "heart beating" in the abdomen
17. An emergency department client who complains of slightly
improved but unrelieved chest pain for 2 days is reluctant to take a
nitroglycerin sublingual tablet offered by the nurse. The client
states, "I don't need that—my dad takes that for his heart. There's
nothing wrong with my heart." Which description best describes the
client's response?
a. Angry
b. Denial
c. Phobic
d. Obsessive-compulsive
18. A client is scheduled for a cardiac catheterization using a
radiopaque dye. The LPN/LVN checks which most critical item before
the procedure?
a. Intake and output
b. Height and weight
c. Peripheral pulse rates
d. Prior reaction to contrast mediapg.
g. 70
B. B. Flush the GT with 50mL of water and clamp the GT to prevent
leakage
C. C. Place the infant in the right lateral position to facilitate gastric
emptying
D. D. Burp the infant after each 10mL of formula administration and
re-feed any volume that is spit up
182. Which intervention is within the scope of practice for a nurse?
A. A. Demonstrating deep breathing and coughing to postoperative
client
B. B. Teaching the use of glucometer to a newly diagnosed diabetic
client
C. C. Presenting support options that are available to those with
cancer
D. D. Discharge teaching about newly prescribed medications
183. The nurse is preparing a client for a mammogram. What
instructions should the nurse provide the client?
A. A. Do not exercise the upper body on the day of the procedure
B. B. Avoid taking aspirin for one week prior to the procedure
C. C. Avoid eating or drinking 6 hours prior to the procedure
D. D. Do not use underarm deodorant on the day of the procedure
184. An older client is transferred to the rehabilitation unit with the
diagnosis of Cerebrovascular Accident (CVA) with left sided hemiplegia.
The nurse addresses the client from the right side, and the client points
to the left leg
and states, "There is a leg in my bed!" What is the best response by
the nurse?
A. A. "Your stroke has impaired your ability to recognize your
paralyzed leg."
B. B. "Look at your legs and you will see that they both belong to
you."
C. C. "Please explain to me what you thing happened to your leg."
D. D. "I know you think there is an extra leg in your bed, but I do not
see it."
185. Which technique should the nurse use to give a Z-track
intramuscular injection?
A. A. Ensure that no air is present in the syringe
B. B. Inject the medication into the dorsal gluteal site
C. C. Select a 22-gauge, 1 inch needle for injection
D. D. Massage the site for 2 minutes after the injectionpg. 71
186. The nurse observe that the IV catheter is no longer in a client's
arm. It is on the bed, and the sheets are moist with IV fluid. The client
is disoriented and states he does not remember pulling the catheter
out. How should the nurse document this situations?
A. A. Client does not remember pulling out the IV
B. B. IV catheter found lying on bed sheets
C. C. IV catheter pulled out by disoriented client
D. D. IV discontinued and wet sheets changed
187. The nurse identifies several findings in an older female who is on
prolonged bed rest. Which finding requires
prompt action by the nurse?
A. A. Heart rate increases of 10 beats per minute
B. B. Bowel movements decrease to 1 every third day
C. C. Urinary output decreases of 250mL in the last 24 hours
D. D. D. Systolic blood pressure decrease of 10mmHg
188. A nurse sees a colleague taking drugs from the hospital unit.
What action should the nurse take?
A. A. Report the incident to the person in charge of the unit or
Nursing supervisor
B. B. Notify the hospital security staff to retrieve the drugs from the
colleague
C. C. Report the colleague to the peer review committee of the
hospital
D. D. Confront the colleague and tell him/her to take the drugs back
to the unit
189. Which term describes 2 or more tissues that compose a structure
and perform a specific function?
A. A. Elastic tissue
B. B. Organ
C. C. System
D. D. Serous membrane
190. How many mL should the nurse document when calculating a
client's 8-hour fluid intake? (Enter the numeric
value only.)
0730 - 4 ounces of orange juice, hardboiled egg, and toast
1130 - 1/2 cup of soup, one half sandwich, and 1/2 cup of apple juice
1300 - vomitus of 100 mL
1400 - voided 250 ml and consumed one 12-ounce can of soft drink
(type your answer in the box below)
1oz = 30mL; so 4oz of orange juice X 30mL = 120mL of orange juice
Then 1 cup = 240; so ½ cup is 120mL of soup and ½ cup of apple juice
is 120mL of apple juice = 240mL total
vomitus is output, not intake, so ignorepg. 72
voided is output, not intake, so ignore
1 oz = 30mL; so 12oz is 12oz X 30mL = 360mL
add them all; 120mL + 240mL + 360mL = 720mL
720
191. A male client is receiving ferrous sulfate (iron), docusate sodium
(Colace) and codeine. He reports that his last bowel movement was 3
days ago. During medication administration, which action should the
nurse implement?
A. A. Offer the client a full glass of water
B. B. Give medications 2 hours apart
C. C. Provide a snack with the medications
D. D. Administer only the docusate sodium
192. The nurse is caring for a primagravida 5 hours after a vaginal
delivery. Which finding should the nurse report immediately to the
charge nurse?
A. A. Pulse rate of 90 beats/minute
B. B. Rubor lochia saturating 3 perineal pads per hour
C. C. Complaints of perineal pain
D. D. Firm fundus between umbilicus and the symphysis pubis
193. A client with recurrent urinary tract infections (UTI) is being
discharged. What instruction is appropriate for the nurse to include in
the discharge teaching plan?
A. A. Drink 3 quarts of water daily
B. B. Avoid swimming in public pools
C. C. Avoid intercourse until all antibiotics have been taken
D. D. Drink 3, 6-ounce cans of cranberry juice daily
194. Which criterion is best for the nurse to use when evaluating a
client's response to an analgesic that was administered for
postoperative pain?
A. A. Amount of medication required to relieve pain
B. B. Activity without guarding or grimacing
C. C. Objective parameters of blood pressure and respirations
D. D. Subjective score on a 1 to 10 pain scale
195. A client is diagnosed with Pericarditis after a Myocardial
Infarction (MI) and asks the nurse, "Why did this happen?" What
explanation should the nurse offer?pg. 73
A. A. The sac surrounding the heart has become inflamed from the
cells damaged by the heart attack
B. B. The space around your heart is filling with fluid and your
healthcare provider will have to explain the
treatment
C. C. The heart cells have been infiltrated by organisms and a
secondary autoimmune reaction has
occurred
D. D. This is an infection of the lining of the heart caused by
bacteria entering through your gums
196. In describing the "at risk" individual for developing Breast
Cancer, the nurse should recognize that which client is at the highest
risk? The woman who is...
A. A. a 40-year-old African American with Hypertension (HTN)
B. B. a 35-year-old with trauma to the breast
C. C. a 32-year-old whose mother had breast cancer
D. D. a 50-year-old Caucasian who has never had a mammogram
197. What technique should the nurse use to administer a medicated
ophthalmic ointment?
A. A. Massage the lashes with the excess ointment that is squeezed
out when shutting the lids
B. B. Place a thin ribbon of ointment into the lower conjunctival sac
from the inner to outer canthus
C. C. Pull both upper and lower lids apart to drop the ointment onto
the anterior surface of the eye
D. D. Wear gloves when placing the tip of the ointment tube in the
center of the lower lid
198. A client is using an incentive spirometer on the first
postoperative day after an inguinal Herniorrghaphy. The nurse should
re-teach the proper use of the spirometer when the client
demonstrates what action?
A. A. Using a tight seal around the mouth piece
B. B. Exhaling slowly after two seconds
C. C. Blowing forcefully into the mouthpiece
D. D. Sitting upright during treatment
199. An 8-year-old recovering from a Celiac Crisis requests a bowl of
cereal for breakfast. Which cereal should the nurse provide?
A. A. Corn flakes
B. B. Granola
C. C. Oatmealpg. 74
D. D. Wheat puffs
E. E. Rice
200. The nurse assumes care of a client who was admitted earlier in
the day for a scheduled Hysterectomy in the morning. Which recorded
assessment data obtained by the admitting registered nurse is
objective? (Select all that apply).
A. A. Anemia
B. B. Menorrhagia
C. C. Tiredness
D. D. Orthostatic hypotension
E. E. Fear
F. F. Nervousness
201. The nurse empties a large amount of serous drainage from a
postoperative client's Hemovac drain. In what order should the nurse
implement these procedures? (Place the first action on top and the last
action on the bottom.)
A. Compress drain... close drain... discard drain... document
202. The nurse should recommend that males over the age of 45
obtain which test to screen for prostatic cancer?
A. A. Prostate-specific antigen (PSA)
B. B. Alpha-fetoprotein radio immunoassay (AFP)
C. C. Ultrasound of the scrotum
D. D. Serum testosterone level
203. The nurse is giving medications to a client who was admitted to
the hospital with a diagnosis of Diabetes Mellitus Type II. After checking
the finger stick glucose at 1630dL, what dose of insulin should the
nurse administer? (enter the numeric value only) (Click on each chart
tab for additional information. Please be sure to scroll to the bottomright corner of each tab to view all information contained in the client's
medical
record.)
8
204. A client is receiving 0.5 grams of a prescription medication that is
dispensed as 500 mg/5mL. How many ml should the PN administer?
(enter the numeric value only. If rounding is required, round to the
nearest
tenth.)
5pg. 75
205. The nurse is receiving a client following an emergency Cesarean
Section (C-Section). Which information is most important for the nurse
to obtain?
A. A. Blood pressure and pulse rate
B. B. Gravida and parity
C. C. Medications received during labor
D. D. Temperature and respiratory rate
206. The nurse is preparing to insert an indwelling catheter for an 89-
year-old client who has severe contractures of both lower extremities.
The client cries in pain when positioned supine while the nurse
attempts to abduct the hips to visualize the perineum. What action
should the nurse take?
A. A. Report to the charge nurse that the client cannot cooperate for
the insertion
B. B. Recruit two UAPs to hold the legs apart while the catheter is
inserted
C. C. Position laterally for posterior access in visualizing the meatus
for insertion
D. D. Pre-medicate the client with a narcotic analgesic to relax the
skeletal muscles
207. An elderly client in the early postoperative period requires close
monitoring due to aging and multisystem changes. The nurse monitors
respirations and auscultates breath sounds frequently. What other
intervention should the nurse implement related to the client's
decreased vital capacity?
A. A. Evaluate pulse oxygen saturation
B. B. Allow extra education time
C. C. Encourage high protein supplements
D. D. Monitor intake and output
208. The nurse can also refer to the external ear as what other known
name...
A. A. Pinna
B. B. Malleus
C. C. Incus
D. D. Cochleapg. 76
209. During immediate postoperative period, which condition has the
highest priority when planning Nursing care?
A. A. Infection
B. B. Respiratory obstruction
C. C. Dehydration
D. D. Cardiac arrest
210. The nurse is providing instructions to the unlicensed assistive
personnel (UAP) preparing to instruction is most important for the
nurse to emphasize?
A. A. Keep the head of the bed raised while the tube feeding is
infusing
B. B. Report any drainage observed around the GT insertion site
C. C. Raise the entire bed while bathing the client to reduce back
strain
D. D. Use plenty of pillows to position the client on the side after
bathing
211. A client is admitted to the rehabilitation unit after a Thrombotic
Cerebrovascular Accident (CVA) with Right Hemiplegia and expressive
aphasia. What intervention should the nurse implement to
communicate with the client?
A. A. Picture communication board
B. B. Request a family member to interpret
C. C. Electronic larynx device
D. D. Dysphagia precautions
212. The nurse is reviewing instructions for the use of pilocarpine eye
drops with a client who has Glaucoma. The client states, "I should have
these drops to anesthetize my eye if I experience pain" What action
should the nurse implement?
A. A. Explain to the client the eye drops do provide pain relief, but
do not anesthetize the eyes
B. B. Reassure the client that the drops will not be needed often
since eye pain in glaucoma is not
common
C. C. Re-teach the client about the action of the eye drops to
decrease pressure in the eye
D. D. Document in the chart that the client understands the action
and use the eye dropspg. 77
213. A client is complaining of muscle fatigue in the lower extremities.
What is the physiological cause of muscle fatigue?
A. A. The depletion of glycogen and energy stores
B. B. Electrical stimulus failure at the neuromuscular junction
C. C. Calcium concentration decrease in the muscle sarcomere
D. D. Hyperoxygenation of the muscle fiber
214. A client asks the nurse to explain the location of the prostate
gland. What is the best response?
A. A. Close the rectal wall the prostate gland sits behind the
symphysis pubis extending around the beginning of the urethra
B. B. At the bottom of the scrotal sac, the prostate gland rests
beneath the testes, held in place by the
spermatic fascia
C. C. Attach to the front and sides of the pubic arch, the prostate is
a mess of cavernous tissue held
together by fibrous tissue
D. D. Located at the lateral edge of the posterior segment of the
testes, the prostate creates a bulge
continuous with the vas deferens
215. A female client is being prepared for a speculum exam. In which
position should the nurse place the client?
A. A. Left Sims
B. B. Semi-Fowler's
C. C. Lithotomy
D. D. Trendelenburg
216. The nurse is caring for an elderly client who has suddenly
become confused after 2 days of vomiting and
diarrhea. What laboratory result should the nurse report first to the
RN?
A. A. Serum potassium 6mEq/L, serum sodium 126mnEq/L, and
serum chloride 115mEq/L
B. B. Glucose tolerance results fasting 80 mg/dL, 1hr: 110mg/dL
2hr: 120 mg/dL, 3hr: 90 mg/dL
C. C. Negative Hepatitis B Surface Antigen, serum total biilirubin 0.
1 mg/dL
D. D. Troponin l < 0.1ng/mL and creatinine kinase MB (CK-MB) 2% of
total 10 milliunits/L
217. While providing oral care for a client who is unconscious, the
nurse positions the client laterally and uses a basin to collect
secretions. Which intervention is best for the nurse to implement?pg. 78
A. A. Swab the oral cavity with a washcloth
B. B. Use oral swabs with normal saline
C. C. Provide a Yankauer tip for oral suction
D. D. Support the head with a small pillow
218. The nurse is caring for a mother who is bottle-feeding and
develops breast engorgement. Which intervention is most effective in
reducing breast engorgement?
A. A. Wearing a tight-fitting bra
B. B. Applying hot packs to the breasts
C. C. Expressing milk from the breast by hand
D. D. Exposing the breasts to air
219. A 6-month old male with Bronchiolitis is admitted to the hospital.
In monitoring the respiratory status of this child, which symptom
indicates the nurse that he is experiencing Respiratory Distress?
A. A. Respiratory of 62 breaths/minute
B. B. Abdominal breathing
C. C. A high-pitched cry
D. D. Dry flushed skin
220. During vital sign assessment of a client, the nurse counts the left
radial pulse at 88, and the pulse oximeter clipped to a finger on the left
hand records a pulse rate of 68 with an oxygen saturation of 95%.
What is the
best initial action by the nurse?
A. A. Count the right radial pulse rate
B. B. Reposition the oximeter clip
C. C. Document a pulse deficit
D. D. Count the apical pulse rate
221. Which client should the nurse assess first?
A. A. A young female client who reports that she is afraid of her
roommate who is psychotic
B. B. An older client who is asking for a priest to offer Last Rites
C. C. A female client who is anxious about being discharged
because she has no assistance at home
D. D. A client who is ambulating with partial weight-bearing after a
total hip replacement [Show Less]