HESI EXIT RN EXAM V3
(Detail Solutions and Resource for the test)
1. A male client with hypertension, who received new antihypertensive prescriptions
... [Show More] at his last
visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is
158/106 and he admits that he has not been taking the prescribed medication because the
drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should
stress that an elevated BP places the client at risk for which pathophysiological condition?
Stroke
secondary
to
hemorrhage
2. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted
client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along
the side rails. What action should the nurse implement?
Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
3. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the
past 12 days. Which assessment finding requires immediate follow-up?
Describes life without purpose
4. A 60-year-old female client with a positive family history of ovarian cancer has developed an
abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap)
smear results are negative. What information should the nurse include in the client’s teaching
plan?
Further evaluation involving surgery may be needed
1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink
plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best
follow-up action by the nurse?
• Review with the client the need to avoid foods that are rich in milk and cream
2. A male client with hypertension, who received new antihypertensive prescriptions at his last
visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106
and he admits that he has not been taking the prescribed medication because the drugs make
him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an
elevated BP places the client at risk for which pathophysiological condition?
• Stroke secondary to hemorrhage
3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client
who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the
side rails. What action should the nurse implement?
• Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the
past 12 days. Which assessment finding requires immediate follow-up?
• Describes life without purpose
5. A 60-year-old female client with a positive family history of ovarian cancer has developed an
abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap)
smear results are negative. What information should the nurse include in the client’s teaching
plan?
• Further evaluation involving surgery may be needed
6. A client who recently underwear a tracheostomy is being prepared for discharge to home.
Which instructions is most important for the nurse to include in the discharge plan?
• Teach tracheal suctioning techniques
7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen
reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is
14 breaths / minute. What action should the nurse implement?
• Document the assessment data
• Rational: reservoir bag should not deflate completely during inspiration and the client’s
respiratory rate is within normal limits.
8. During shift report, the central electrocardiogram (EKG) monitoring system alarms.
Which client alarm should the nurse investigate firs?
• Respiratory apnea of 30 seconds
9. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action
should the nurse take first?
• Check the client for lacerations or fractures
10. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client
tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a
headache. Which action should the nurse take first?
• Inform the anesthesia care provider
11. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart
sounds. To determine if an S3 heart sound is present, what action should the nurse take first?
• Listen with the bell at the same location
12. A 66-year-old woman is retiring and will no longer have a health insurance through her place of
employment. Which agency should the client be referred to by the employee health nurse for
health insurance needs?
• Medicare
13. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset.
What snack should the nurse instruct the client to take with the tetracycline?
• Toasted wheat bread and jelly
14. Following a lumbar puncture, a client voices several complaints. What complaint indicated to
the nurse that the client is experiencing a complication?
• “I have a headache that gets worse when I sit up”
• “I am having pain in my lower back when I move my legs”
• “My throat hurts when I swallow”
• “I feel sick to my stomach and am going to throw up”
15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with
incontinence. Which action should the nurse implement?
• Obtain a clean catch mid-stream specimen
16. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are
in keeping with the child’s dietary restrictions. Which foods are contraindicated for this child?
• Foods sweetened with aspartame
17. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the
circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which
response should the circulating nurse provide?
• Direct the nurse to continue the surgical hand scrub for a 5 minute duration
18. Which breakfast selection indicates that the client understands the nurse’s instructions about
the dietary management of osteoporosis?
Bagel with jelly and skim milk
19. The charge nurse of a critical care unit is informed at the beginning of the shift that less than
the optimal number of registered nurses will be working that shift. In planning assignments,
which
client
should
receive
the most care hours by a registered nurse (RN)?
•
An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a
Foley catheter and soft wrist restrains applied
20. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s
office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the
bottom of the child’s foot. Which action should the nurse implement first?
• Cleanse the foot with soap and water and apply an antibiotic ointment • Provide
teaching about the need for a tetanus booster within the next 72 hours.
• have the mother check the child's temperature q4h for the next 24 hours
• transfer the child to the emergency department to receive a gamma globulin injection
21. The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been
applying triple antibiotic ointment for two days, but there has been no improvement.” What
Stop using the ointment and encourage complete drying of the feet and wearing
clean socks.
instruction should the nurse provide?
•
22. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences
• Bradycardia and constipation
• Lethargy and lack of appetite
• Muscle cramping and dry, flushed skin
• Palpitations and shortness of breath
23. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow
vision and palpitations. Which finding is most important for the nurse to assess to the client?
• Obtain a list of medications taken for cardiac history
24. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of
D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many
ml/hour? (Enter numeric value only.)
• 75
• Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour /
1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour
25. The pathophysiological mechanism are responsible for ascites related to liver failure?
(Select all that apply)
•
•
Fluid shifts from intravascular to interstitial area due to decreased serum protein
Increased hydrostatic pressure in portal circulation increases fluid shifts into
abdomen
Increased circulating aldosterone levels that increase sodium and water retention
26. The nurse is auscultating a client’s heart sounds. Which description should the nurse use to
document this sound? (Please listen to the audio first to select the option that applies)
• Murmur
• Rationale: A murmur is auscultated as a swishing sound that is associated with the blood
turbulence created by the heart or valvular defect.
27. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant.
The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration
of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value
only. If rounding is required, round to the nearest tenth)
• 0.4
• rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
28. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for
four days. What assessment is most important for the nurse to complete?
• Auscultate the client's bowel sounds
• Observe for edema around the ankles
• Measure the client’s capillary glucose level
• Count the apical and radial pulses simultaneously
• Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and
frequently causes constipation, so it is most important to Auscultate the client's bowel
sounds
29. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining
of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if
she stops breathing, and she asks the nurse to document this in her medical record. What action
should the nurse implement?
• Ask the client to discuss “do not resuscitate” with her healthcare provider
30. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has
developed diarrhea. The client has a new prescription to change the feeding to half strength.
What intervention should the nurse implement?
• Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour
31. A female client reports that her hair is becoming coarse and breaking off, that the outer part of
her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is
best for the nurse to ask?
• Have you noticed any changes in your fingernails?
• Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
32. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and
malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting
up blood. What assessment finding warrants immediate intervention by the nurse?
• Capillary refill of 8 seconds
• bruises on arms and legs
round and tight abdomen
• pitting edema in lower legs
33. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs
the form as a witness. What are the legal implications of the nurse’s signature on the client’s
surgical consent form? (Select all that apply)
• The client voluntarily grants permission for the procedure to be done
• The client is competent to sign the consent without impairment of judgment
• The client understands the risks and benefits associated with the procedure
34. Following surgery, a male client with antisocial personality disorder frequently requests that a
specific nurse be assigned to his care and is belligerent when another nurse is assigned. What
action should the charge nurse implement?
• Advise the client that assignments are not based on clients requests
35. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation
implant. While providing care, the nurse finds the radiation implant in the bed.
What action should the nurse take?
• Place the implant in a lead container using long-handled forceps
36. The client with which type of wound is most likely to need immediate intervention by the
nurse?
• Laceration
• Abrasion
• Contusion
• Ulceration
• Rationale: A laceration is a wound that is produced by the tearing of soft body tissue.
This type of wound is often irregular and jagged. A laceration wound is often
contaminated with bacteria and debris from whatever object caused the cut.
37. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma.
Which intervention has the highest priority for inclusion in this client’s plan of care?
• Monitor blood pressure frequently
• Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may
precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but
may be cured completely by surgical removal. Although pheochromocytoma has
classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome,
multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—
there are now 10 genes that have been identified as sites of mutations leading to
pheochromocytoma.
38. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates
the head of the bed 30 degrees. What is the reason for this intervention?
• To reduce abdominal pressure on the diaphragm
• to promote retraction of the intercostal accessory muscle of respiration
• to promote bronchodilation and effective airway clearance
• to decrease pressure on the medullary center which stimulates breathing
• Rationale: a semi-sitting position is the best position for matching ventilation and
perfusion and for decreasing abdominal pressure on the diaphragm, so that the client
can maximize breathing.
39. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the
gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal
muscle. What is the most likely explanation for failure to locate the gallbladder by palpation?
• The client is too obese
• Palpating in the wrong abdominal quadrant
• Deeper palpation technique is needed
• The gallbladder is normal
• Rationale: a normal healthy gallbladder is not palpable
40. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased
anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding,
she stopped taking her antianxiety medications, but thinks she may need to start taking them
again because of her increased anxiety. What response is best for the nurse to provide this
woman?
• describe the transmission of drugs to the infant through breast milk
Inform her that some antianxiety medications are safe to take while
breastfeeding
• encourage her to use stress relieving alternatives, such as deep breathing exercises
•
• Explain that anxiety is a normal response for the mother of a 3-week-old.
• Rationale: there are several antianxiety medications that are not contraindicated for
breastfeeding mothers.
41. An older male client with a history of type 1 diabetes has not felt well the past few days and
arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately,
confused, and cannot remember when he took his last dose of insulin or ate last. What action
should the nurse implement first?
• Start an intravenous (IV) infusion of normal saline
• obtain a serum potassium level
• administer the client's usual dose of insulin
• assess pupillary response to light
• Rationale: the nurse should first start an intravenous infusion of normal saline to
replace the fluids and electrolytes because the client has been vomiting, and it is
unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting,
and abdominal cramping are all suggestive of hyperglycemia, which also contributes to
diuresis and fluid electrolyte imbalance.
42. A client who received multiple antihypertensive medications experiences syncope due to a drop
in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s
scheduled antihypertensive medication?
• increased urinary clearance of the multiple medications has produced diuresis and
lowered the blood pressure
• the antagonistic interaction among the various blood pressure medications has reduced
The additive effect of multiple medications has caused the blood pressure to
drop too low
their effectiveness
•
• the synergistic effect of the multiple medications has resulted in drug toxicity and
resulting hypotension
43. Which client is at the greatest risk for developing delirium?
• An adult client who cannot sleep due to constant pain.
• an older client who attempted 1 month ago
• a young adult who takes antipsychotic medications twice a day
• a middle-aged woman who uses a tank for supplemental oxygen
44. Which intervention should the nurse include in a long-term plan of care for a client
with Chronic Obstructive Pulmonary Disease (COPD)?
• Reduce risks factors for infection
• Administer high flow oxygen during sleep
• Limit fluid intake to reduce secretions
• Use diaphragmatic breathing to achieve better exhalation
45. Which location should the nurse choose as the best for beginning a screening
program for hypothyroidism?
• A business and professional women's group.
• An African-American senior citizens center
• A daycare center in a Hispanic neighborhood
• An after-school center for Native-American teens
A female client has been taking a high dose of prednisone, a corticosteroid, for several
months. After stopping the medication abruptly, the client reports feeling “very tired”.
Which nursing intervention is most important for the nurse to implement?
• Measure vital signs
46.
• Auscultate breath sounds
• Palpate the abdomen
• Observe the skin for bruising
47.
A male client reports the onset of numbness and tingling in his fingers and
around his mouth. Which lab is important for the nurse to review before
contacting the health care provider?
• capillary glucose
• urine specific gravity
• Serum calcium
• white blood cell count
48.
What explanation is best for the nurse to provide a client who asks the
purpose of using the log-rolling technique for turning?
• working together can decrease the risk for back injury
• The technique is intended to maintain straight spinal alignment.
• Using two or three people increases client safety.
• turning instead of pulling reduces the likelihood of skin damage [Show Less]