HESI EXIT Exam V5 with Answers
The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority
... [Show More] nursing diagnosis?
While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?
The nurse enters the room as a 3-year-old is having a generalized seizure. Which intervention should the nurse do first?
The nurse is reviewing a depressed client’s history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to
A client has just returned to the medical-surgical unit following segmental lung resection. After assessing the client, the first nursing action would be to
While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?
A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
A 15-year-old client with a lengthy confining illness is at risk for altered growth and development of which task?
Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?
The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is
The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds
The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
A 23-year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize?
The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?
The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?
Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes?
A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?
A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at the highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child?
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
A priority goal of involuntary hospitalization of the severely mentally ill client is
The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend
The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time?
The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings?
A 57-year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the
For a 6-year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
Following mitral valve replacement surgery, a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute?
An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should
The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate postoperative period?
A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parents remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that
A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?
A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breastfeed the infants. Which of the following is based on sound rationale?
The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?
Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?
A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when “his eyes rolled upward.” The nurse recognizes this as what type of side effect?
Which of the following measures would be appropriate for the nurse to teach the parent of a nine-month-old infant about diaper dermatitis?
A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child’s constantly saying “no” and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
Which behavioral characteristic describes the domestic abuser?
Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing
During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?
A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression”?
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action?
An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?
On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize
A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?
In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in
In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?
The nurse is performing a physical assessment on a client with insulin-dependent diabetes mellitus. Which client complaint calls for immediate nursing action?
The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be 64 In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test?
The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has
A client was admitted with a diagnosis of pneumonia. When auscultating the client’s breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect?
Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. This action by the nurse will assess
The nurse is providing instructions for a client with asthma who is sensitive to house dust mites. Which information about the prevention of asthma episodes would be the most helpful to include during the teaching?
A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?
The nurse is caring for a client with Parkinson’s disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?
The nurse is assessing a 12-year-old who has Hemophilia A. Which finding would the nurse anticipate?
The nurse is assessing a newborn infant and observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. A priority maternal assessment by the nurse should be to ask about
A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which nursing approach should be the priority?
The new graduate nurse interviews for a position in a nursing department of a large health care agency, described by the interviewer as having shared governance. Which of these statements best illustrates the shared governance model?
The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?
A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis
A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?
A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal?
The RN is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application?
The nurse would expect which eating disorder to have the greatest fluctuations in potassium?
When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?
The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality?
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is
At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially
A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to
A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse’s immediate attention?
You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which indicates further teaching may be needed by the client?
When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority?
The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport?
On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the RN anticipate finding?
A child with Tetralogy of Fallot visits the clinic several weeks before planned surgery. The nurse should give priority attention to
When teaching new parents to prevent Sudden Infant Death Syndrome (SIDS) what is the most important practice the nurse should instruct them to do?
A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client knowing that gradual emptying is preferred over complete emptying because it
The nurse is assessing a client with a deep vein thrombosis. Which of the following signs and/or symptoms would the nurse anticipate finding?
A 6 year-old female is diagnosed with recurrent urinary tract infections (UTI). Which one of the following instructions would be best for the nurse to tell the caregiver?
A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client’s obstetric history by the nurse?
On admission to the hospital a client with an acute asthma episode has intermittent nonproductive coughing and a pulse oximeter reading of 88%. The client states, “I feel like this is going to be a bad time this admission. I wish I would not have gone into that bar with all those people who smoke last night.” Which nursing diagnoses would be most important for this client?
A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client?
While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication?
While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed (“knocked out”). After recovering the tooth, the initial response should be to
The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best response by the nurse should be that
During the beginning shift assessment of a client with asthma and is receiving oxygen per nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding?
During the care of a client with Legionnaire’s disease, which finding would require the nurse’s immediate attention?
A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a
The nurse is assigned to a client with Parkinson’s disease. Which findings would the nurse anticipate?
Which of these statements by the nurse is incorrect to use to reinforce information about cancers to a group of young adults?
A 67 year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infraction (MI). The priority nursing diagnosis for this client during the immediate 24 hours is
With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select?
The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?
A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the “evil eye.” The nurse should communicate to other personnel that the appropriate approach is to
A client is admitted for COPD. Which finding would require the nurse’s immediate attention?
A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would need to be explored by the nurse to clarify information?
A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager do initially?
The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information?
A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not voided in 14 hours. When assessing for bladder distention, the best method for the nurse to use is to assess for
Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective?
A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to
The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?
The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?
The nurse would teach a client with Raynaud’s phenomenon that it is most important to
The nurse is caring for a client with status epileptics. The most important nursing assessment of this client is
A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note
The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the “unfreezing” phase of change. With this approach and phase the nurse manager should
Which of these tests with frequency would the nurse expect to monitor for the evaluation of clients with poor glycemic control in persons aged 18 and older?
At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about preconception diet changes. Which of the statements made by the nurse is best?
A client comes into the community health center upset and crying stating “I will die of 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 client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?
The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by
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
Which finding would be the most characteristic of an acute episode of reactive airway disease?
Which tasks, if delegated by the new charge nurse to a unlicensed assistive personnel (UAP), would require intervention by the nurse manager?
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 the medication?
The nurse uses the DRG (Diagnosis Related Group) manual to
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. Which of these lab reports sent to the clinic need to be called to the teens health care provider within the next hour?
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 the nurse would perform is to
To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the
The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins?
The nurse is teaching a 27 year-old client with asthma about the management of their therapeutic regime. Which statement would indicate the need for additional instruction?
While caring for a child with Reye’s Syndrome, the nurse should give which action the highest priority?
A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?
A confused client has been placed in physical restraints by order of the health care provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?
A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client
A client who is terminally ill has been receiving high doses of an opiod analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli,what orders would the nurse expect from the health care provider?
Which of these clients would the triage nurse request for the health care provider to examine immediately?
An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for trachea esophageal fistula. The mother asks:”When can the tube can be used for feeding?” The nurse’s best response would be which of these comments?
A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider’s diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first?
The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?
The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. Which of these should be emphasized to the client to avoid?
A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy?
A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse’s contribution and begins to find objections to the suggestion. The nurse manager’s best response is to
The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses immediate attention?
A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?
The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?
The nurse is caring for a 5 year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity?
The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect? [Show Less]