HESI EXIT EXAM Version 2 | QUESTIONS AND VERIFIED ANSWERS (2023/ 2024 Latest Update)
QUESTION
While assessing a client who is admitted with heart
... [Show More] failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement?
A. Obtain sputum sample
B. Document degree of edema
C. Initiate hourly urine output measurement
D. Administer intravenous diuretics
Answer:
A. Obtain sputum sample
QUESTION
A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (descending order)
Answer:
1. Observe breathing patterns
2. Assess blood pressure
3. Measure body temperature
4. Palpate for pedal edema
QUESTION
A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation?
A. Potassium 3.5 mEq/L
B. Fingertips feel numb
C. Sodium 135 mEq/L
D. Cervical spine stiffness
Answer:
B. Fingertips feel numb
QUESTION
An older client is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication?
A. currently prescribed medications
B. Client's healthcare power of attorney
C. Increasing confusion of the client
D. Fall at home as reason for admission
Answer:
C. Increasing confusion of the client
QUESTION
The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs (2kg) in 24 hours and an elevated central venous pressure for a client with full thickness burns. Which intervention should the nurse implement?
A. Auscultate for irregular heart rate
B. Review arterial blood gases results
C. Measure ankle circumference
D. Document abdominal girth
Answer:
A. Auscultate for irregular heart rate
QUESTION
The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply)
A. Administer a dose of insulin per sliding scale for a client with Type 2 DM
B. Start the second blood transfusion for a client 12 hours following a BKA
C. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperatively
D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
Answer:
A. Administer a dose of insulin per sliding scale for a client with Type 2 DM
D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
QUESTION
The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?
A. Core strengthening
B. Aerobic exercise
C. Weight-bearing exercise
D. Muscle stretching and toning
Answer:
B. Aerobic exercise
QUESTION
A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse?
A. CT scan that was performed 6 months earlier
B. Metal hip prosthesis was placed 20 years ago
C. Report of client's sobriety for the last 5 years
D. Takes metformin for type 2 diabetes mellitus
Answer:
D. Takes metformin for type 2 diabetes mellitus
QUESTION
A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale of insulin aspart every 6h are prescribed. What actions should the nurse include in this client's plan of care? (Select all that apply)
A. Do not contaminate the insulin aspart so that it is available for IV use
B. Review with the client proper foot care and prevention of injury
C. Teach subcutaneous injection technique, site rotation, and insulin management
D. Coordinate carbohydrate controlled meals at consistent times and intervals.
E. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose
F. Fingerstick glucose assessments every 6h with meals
Answer:
B. Review with client proper foot care and prevention of injury
C. Teach subcutaneous injection technique, site rotation, and insulin management
D. Coordinate carbohydrate controlled meals at consistent times and intervals
F. Fingerstick glucose assessments every 6h with meals
QUESTION
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?
A. A 14yo client with anorexia nervosa who is refusing to eat the evening snack
B. A 16yo client diagnosed with major depression who refuses to participate in group
C. A 17yo client diagnosed with bipolar disorder who is pacing around the lobby
D. An 18yo client with antisocial behavior who is being yelled at by other clients
Answer:
D. An 18yo client with antisocial behavior who is being yelled at by other clients
QUESTION
A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement?
A. Obtain the client's 24-hour dietary recall
B. Document mucosal membrane status
C. Schedule a consult with a nutritionist
D. Initiate prescribed intravenous fluids
Answer:
D. Initiate prescribed intravenous fluids
QUESTION
A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teach the parents to report which sign of overdose?
A. Bradycardia
B. Tachypnea
C. Hypertension
D. Coughing
Answer:
A. Bradycardia
QUESTION
Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?
A. Upper body muscle strength
B. Balance and posture
C. Risk for disuse syndrome
D. Pressure sore risk
Answer:
A. Upper body muscle strength
QUESTION
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?
A. A retraining program will need to be initiated when the child returns home.
B. Diapering will be provided since hospitalization is stressful to preschoolers
C. A potty chair should be brought from home so he can maintain his toileting skills
D. Children usually resume their toileting behaviors when they leave the hospital
Answer:
D. Children usually resume their toileting behaviors when they leave the hospital [Show Less]