HESI EXIT EXAM(WALDEN EXAM
LATEST 2023) GUARANTEED SUCCESS
1. A client tells the nurse that he is suffering from insomnia. Which information is
most
... [Show More] important for the nurse to obtain?
A. The client's usual sleeping pattern
B. Whether the client smokes
C. How much liquid the client consumes before bedtime
D. The amount of caffeine that the client consumes
during the day
Rationale:
The first thing to determine is the client's usual sleeping pattern and how it has changed to become what
the client describes as insomnia. Options B, C, and D provide additional information after option A is
ascertained.
2. A client has been on a mechanical ventilator for several days. What should the nurse use to
document and record this client's respirations?
A. The respiratory settings on the ventilator
B. Only the client's spontaneous respirations
C. The ventilator-assisted respirations minus the client's
independent breaths
D. The ventilator setting for respiratory rate and the client initiated respirations
Rationale:
The nurse should count the client's respirations and document both the respiratory rate set by the ventilator
and the client's independent respiratory rate. Never rely strictly on option A. Although the client's
spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record
machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture
of the client.
3. Six hours following thoracic surgery, a client has the following arterial blood gas (ABG)
findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention
should the nurse implement based on these results?
A. Increase the oxygen flow rate from 4 to 10
L/min per nasal cannula.
B. Assess the client for pain and administer pain medication
as prescribed.
C. Encourage the client to take short shallow breaths for 5
minutes.
D. Prepare to administer sodium bicarbonateIV over 30
minutes.
Rationale:
These ABGs reveal respiratory alkalosis, and treatment depends on the underlying cause. Because the
client is only 6 hours postoperative, he orshe should be assessed for pain because treating the pain will
correct theunderlying problem. A PaO2 of 96 mm Hg does not indicate the need foran increase in oxygen
administration. The PaCO2 indicates mild hyperventilation, so option C is not indicated. In addition, it is
very difficult to change one's breathing pattern. The use of sodium bicarbonate is indicated for the
treatment of metabolic acidosis, not respiratory alkalosis.
4. A 77-year-old female client states that she has never been so largearound the waist and that she
has frequent periods of constipation.Colon disease has been ruled out with a flexible
sigmoidoscopy. Which information should the nurse provide to this client?
A. As women age, they often become rounder
in the middle because they do not exerciseproperly.
B. Further assessment is indicated becauseloss of abdominal
muscle tone and constipation do not occur with aging.
C. With age, more fatty tissue develops in theabdomen and
decreased intestinal movement can cause constipation.
D. Because there is no evidence of a diseasedcolon, there is no
need to worry about
abdominal size.
Rationale:
With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist.
Slowing peristalsis also affects the emptyingof the colon, resulting in constipation. Option A is not the
primary reason for the changes in body structure. Option B is not indicated because loss of muscle tone
and constipation are age-related changes.
Option D dismisses the client's concerns and does not help herunderstand the changes that
she is experiencing.
5. A mother of a 12-year-old boy states that her son is short and she fears that he will always be
shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she
was 12years of age. To provide health teaching, which question is most important for the nurse
to ask this mother?
A. "Is your son's short stature a social
embarrassment to him or the family?"
B. "What types of foods do both your childreneat now and what
did they eat when they were infants?"
C. "Did any significant trauma occur with thebirth of your son?"
D. "Did your daughter also start her menstrual
period at 12 years of age?"
Rationale:
Girls are expected to mature sexually and grow physically sooner than boys. Furthermore, girls only
grow an average of 2 inches after menses begins. Option A is not appropriate at this time. The mother is
worried that something is wrong with her son physically. Option B has less to dowith stature than growth
and development. Option C is not related to growth hormone deficiencies, which are idiopathic (without
known causes).
Which information is most concerning to the nurse when caring for an older clientwith bilateral
cataracts?
A. States having difficulty with color perception
B. Presents with opacity of the lens upon assessment
C. Complains of seeing a cobweb-type structure inthe visual
field
D. Reports the need to use a magnifying glass to seesmall print
Rationale:
Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes
a medical emergency. Clients with cataracts are atincreased risk for retinal detachment. Distorted color
perception, opacity of the lens, and gradual vision loss are expected signs and symptom of cataracts
but donot need immediate attention.
2.When caring for a client hospitalized with Guillain-Barré syndrome, which information is most
important for the nurse to report to the primary health careprovider?
A. Ascending numbness from the feet to the knees
B. Decrease in cognitive status of the client
C. Blurred vision and sensation changes
D. Persistent unilateral headache
Rationale:
A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist
the client with mechanical ventilation. A primary health careprovider will need to be contacted
immediately. Options A, C, and D are findings associated with Guillain-Barré syndrome that should also
be reported but are not ascritical as the client's hypoxic status.
3. A client is admitted with a diagnosis of leukemia. This condition is manifestedby which of the
following?
A. Fever, elevated white blood count, elevatedplatelets
B. Fatigue, weight loss and anorexia, elevated redblood cells
C. Hyperplasia of the gums, elevated white bloodcount,
weakness
D. Hypocellular bone marrow aspirate, fever,decreased
hemoglobin level
Rationale:
Hyperplastic gums, weakness, and elevated white blood count are classic signs ofleukemia. Options A,
B, and D state incorrect information for symptoms of leukemia.
4. The nurse enters the examination room of a client who has been told by her health care provider that
she has advanced ovarian cancer. Which response by thenurse is likely to be most supportive for the
client?
A. "I know many women who have survived ovariancancer."
B. "Let's talk about the treatments of ovariancancer."
C. "In my opinion I would suggest getting a second opinion [Show Less]