2019 PN Hesi Exit V1
Question 1
A school-age client with diabetes is placed on an intermediate- acting insulin and regular
insulin before breakfast and
... [Show More] before dinner. She will receive a snack of milk and cereal at
bedtime. What does the nurse tell the client the snack is intended to do?
You Selected:
• Prevent late night hypoglycemia.
Correct response:
• Prevent late night hypoglycemia.
Question 2
A well-known public official of a small community is admitted to the emergency
department following an episode of chest pain.
Several nurses from the medical unit are aware of the admission and access the official’s
electronic medical record to obtain a status update. What is the best response for the
nurse manager to make to the nurses regarding this situation?
You Selected:
• “Assessing the official’s medical record is a breach of
confidentiality.”
Correct response:
• “Assessing the official’s medical record is a breach of
confidentiality.”
Question 3
A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white
blood cell (WBC) count, especially the neutrophil count, is low. What is the most
important intervention the nurse should teach the parents?
You Selected:
• Protect your child from infections because his resistance to infection is
decreased
Correct response:
• Protect your child from infections because his resistance to infection is
decreased
Question 4
The nurse is caring for a client with influenza. The most effective way to decrease the
spread of microorganisms is:
You Selected:
• placing the client in isolation.
Correct response:
• washing the hands frequently.
Question 5
A client with a history of hypertension has been prescribed a new antihypertensive
medication and is reporting dizziness. Which is the best way for the nurse to assess
blood pressure?
You Selected:
• in the supine, sitting, and standing positions
Correct response:
• in the supine, sitting, and standing positions
Question 6
A client has a soft wrist-safety device. Which assessment finding should the nurse
investigate further?
You Selected:
• cool, pale fingers
Correct response:
• cool, pale fingers
Question 7
A nurse is caring for a female client before surgery. The client states that she is glad that
she will not be going through menopause as a result of her surgery and is only having
her uterus removed. The nurse reviews the consent form and notes that the surgery is for
a total abdominal hysterectomy with a salpingo-oophorectomy. What should the nurse
do in this situation?
You Selected:
• Contact the surgeon to explain that the client needs further clarification
regarding surgery.
Correct response:
• Contact the surgeon to explain that the client needs further clarification
regarding surgery.
Question 8
A young client diagnosed with schizophrenia is talking with the nurse and says, "You
know, when I thought everyone was out to get me, I was staying in my apartment all the
time. Now, I would like to get out and do things again." What is the best initial response
by the nurse?
You Selected:
• "What activities did you enjoy in the past?"
Correct response:
• "What activities did you enjoy in the past?"
Question 9
A client with anemia has been admitted to the medical-surgical unit. Which assessment
findings are characteristic of iron deficiency anemia?
You Selected:
• nausea, vomiting, and anorexia
Correct response:
• dyspnea, tachycardia, and pallor
Question 10
The nurse is discontinuing an intravenous catheter on a 10-year-old client with
hemophilia. What would be the most important intervention for this client?
You Selected:
• Apply firm pressure on the site for 5 minutes after removal.
Correct response:
• Apply firm pressure on the site for 5 minutes after removal.
Question 11
When a client returns from the recovery room postmastectomy, an initial postoperative
assessment is performed by the nurse. What is the nurse’s priority assessment?
You Selected:
• checking the dressing, drain, and amount of drainage
Correct response:
• assessing the vital signs and oxygen saturation levels
Question 12
A client with an uncomplicated term pregnancy arrives at the labor- and-delivery unit in
early labor saying that she thinks her water has broken. What is the nurse’s best action?
You Selected:
• Ask what time this happened and note the color, amount, and odor of the fluid.
Correct response:
• Ask what time this happened and note the color, amount, and odor of the fluid.
Question 13
When documenting the care of a client, the nurse is aware of the need to use
abbreviations conscientiously and safely. This includes
You Selected:
• ensuring the abbreviations are understandable to clients who may seek access
to their health records
Correct response:
• limiting abbreviations to those approved for use by the institution
Question 14
During routine prenatal screening, a nurse tells a client that her blood sample will be
used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP
testing indicates?
You Selected:
• "This screening indicates if your baby's lungs are mature."
Correct response:
• "This test will screen for spina bifida, Down syndrome, or other genetic
defects."
Question 15
A client is recovering from an infected abdominal wound. Which foods should the nurse
encourage the client to eat to support wound healing and recovery from the infection?
You Selected:
• chicken and orange slices
Correct response:
• chicken and orange slices
Question 16
A nurse suspects that the laboring client may have been physically abused by her partner.
What is the most appropriate intervention by the nurse?
You Selected:
• Collaborate with the interprofessional team to make a referral to social services.
Correct response:
• Collaborate with the interprofessional team to make a referral to social services.
Question 17
A client is newly diagnosed with asthma. While learning to use a metered dose inhaler
(MDI) for delivery of a short-term beta agonist, the client asks if a spacer is
appropriate to use with this device. What is the nurse’s best response?
You Selected:
• “No, a spacer is not recommended because it can increase the risk of developing
oropharyngeal candidiasis.”
Correct response:
• “Yes, a spacer is recommended because it increases the amount of medication that
is delivered to the lungs.”
Question 18
The nurse is planning care for a client who had surgery for abdominal aortic aneurysm
repair 2 days ago. The pain medication and the use of relaxation and imagery techniques
are not relieving the client’s pain, and the client refuses to get out of bed to ambulate as
prescribed. The nurse contacts the health care provider (HCP), explains the situation,
and provides information about drug dose, frequency of administration, the client’s vital
signs, and the client’s score on the pain scale. The nurse requests a prescription for a
different, or stronger, pain medication. The HCP tells the nurse that the current
prescription for pain medication is sufficient for this client and that the client will feel
better in several days. What should the nurse do next?
You Selected:
• Explain to the HCP that the current pain medication and other strategies are not
helping the client and it is making it difficult for the client to ambulate as
prescribed.
Correct response:
• Explain to the HCP that the current pain medication and other strategies are not
helping the client and it is making it difficult for the client to ambulate as
prescribed.
Question 19
The nurse is making a room assignment for a client whose laboratory test result indicate
pancytopenia. Which client should the nurse put into the same room with the client with
pancytopenia?
You Selected:
• a client with digoxin toxicity
Correct response:
• a client with digoxin toxicity
Question 20
A community health nurse provides a client with information about a local support
group for those with multiple sclerosis. Providing this information is an example of
which of the following?
You Selected:
• A referral.
Correct response:
• A referral.
Question 21
A nurse working on a neurologic floor has received reports on four clients. After
identifying priority assessment data for each client, which client should the nurse
investigate first?
You Selected:
• the client admitted after a head injury in a motor vehicle who reports nausea
Correct response:
• the client admitted after a head injury in a motor vehicle who reports nausea
Question 22
The mother of an adolescent client who is diagnosed with oppositional defiant disorder
tells the nurse that she has read extensively on this disorder and does not believe the
diagnosis is correct for her daughter. Which response by the nurse is appropriate?
You Selected:
• “Tell me what you’ve found in your reading that’s leading
you to that conclusion.”
Correct response:
• “Tell me what you’ve found in your reading that’s leading you to that
conclusion.”
Question 23
A nurse prepares a client's medication by reconstituting a multi-dose vial of medication.
What other nursing interventions should the nurse take? Select all that apply.
You Selected:
• Label the vial with the strength of the medication.
• Store the multi-dose vial in a secure place.
• Initial the vial as the person reconstituting the medication.
Correct response:
• Label the vial with the strength of the medication.
• Store the multi-dose vial in a secure place.
• Initial the vial as the person reconstituting the medication.
Question 24
Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital
food. Hospital policy discourages food from outside the hospital. The nurse should
next:
You Selected:
• discuss the situation and possible courses of action with the dietitian and the
client.
Correct response:
• discuss the situation and possible courses of action with the dietitian and the
client.
Question 25
After a plaster cast has been applied to the arm of a child with a fractured right
humerus, the nurse completes discharge teaching. The nurse should evaluate the
teaching as successful when the mother agrees to seek medical advice if the child
experiences which symptom?
You Selected:
• fussiness and reports that the cast is heavy
Correct response:
• inability to extend the fingers on the right hand
Question 26
While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at
the nurse's clinic. What is the
nurse's most appropriate response?
You Selected:
• "I'm sorry, I can't disclose client information."
Correct response:
• "I'm sorry, I can't disclose client information."
Question 27
When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24
hours ago, the nurse determines that the fundus is firm but to the right of midline.
Based on this finding, the nurse should further assess for which complication?
You Selected:
• urinary retention
Correct response:
• urinary retention
Question 28
Which situation [Show Less]