HESI RN EXIT EXAM QUESTIONS AND ANSWERS
1. The Nurse is caring for a client admitted with a spontaneous pneumothorax. Which action should the nurse
... [Show More] include in the client’s plan of care?
a. Give bronchodilators by endotrac route
b. Monitor bubbling of chest unit until water-seal chamber
c. Sch client for hyberbanic O2 therapy (HBOT)
d. Administer antibiotics via long line IV cath
2. Following a cataract extraction and intraocular lens implantation, a client in the day surgery unit is reporting nausea.
a. Position the cline to use an emesis basin
b. Administer PRN antiemetic med IV
c. Protect the operative eye from any risk for trauma
d. Withhold diet progression until nausea subside
3. A group of nurses implement a pilot study to eval a proposed evidence based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which actions should be taken (SATA)
a. Obtain informed consent from clients who rec care
b. Arrange in-service training thru the Education Dept
c. Submit a sentinel event report to the research committee
d. Propose clinical prac guidelines to the nursing committee
e. Invite data review by the QI Dep
4. A client is admitted with hypoparathyroidism. Which lab value indicates the nurse should place a client on a telemetry monitor?
a. Calcium 6.5 mg/DL or 0.25 mmol/L
b. Potassium 5.0 mEq/L or mmol/L
c. Sodium 132
d. Magnesium 2.0 or 0.85 mmol/L
5. The RN is assessing a client with an AV fistula who has been rec hemodialysis for 2 years. The nurse auscultates a bruit over the site of the clients fistula. What action should the nurse take/
a. Contact the dialysis unit to r/x the next tx
b. Document the finding in the EMR
c. Elevate the affected arm on 2 pillows immediately
d. Compare the BP readings in both arms
6. The nurse is completing the admission assessm. Of a 3 y/o who is admitted w/ bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased ICP/
a. BP fluctuations and syncope
b. Tachycardia and tachypnea
c. Increased head circumference and bulging fontanels
d. Sluggish and unequal pupillary responses
7. The nurse is assisting the HCP with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?
a. Chest tube insertion tray
b. Ventilator
c. Intubation Tray
d. Crash Cart
8. When conducting diet teaching for a client who was dx with a MI, which snack foods should the nurse encourage the client to eat? (SATA)
a. Fresh turkey slices and berries
b. Raw unsalted almonds and apples
c. Chicken bouillon soup and toast
d. Fresh veggies with mayo dip
e. Soda crackers and PB
9. The nurse is developing a plan of care for a client who reports intermittent claudication and who is newly dx w/ peripheral vas disease. Which outcome should the RN include in the plan of care for client?
a. The nurse will show the client how to perform stress mgmt. tech
b. The clients skin on the lower legs will be intact at the next clinical visit
c. The nurse will monitor the clients skin condition for color changes
d. The nurse will instruct clients fam about the prescribed diet
10. Which assessment finding of a postmenopausal woman necessitates a referral by the RN to a HCP for eval of thyroid functioning?
a. Cold sesntivity
b. Slow weight loss
c. Muscle weakness
d. Leg Numbness
11. The RN is planning to teach infant care and peventitive measures for SIDS to group of new parents. Which estimation is most important for the nurse to include?
a. Ensure that the infants crib mattress is firm
b. Swaddle the infant in a blanket for sleeping
c. Prop the infant with a pillow when in a side lying positon
d. Place the infant in prone position whenever possible
12. A client at 36 weeks gestation comes to the labor and delivery observation unit complaining of “leaking water”. Based on the client’s complaint, what action should the nurse take?
a. Admit the client to labor and delivery if mucus if sound in the vagina vault.
b. If nitrazine paper placed in the vaginal area turns blue, admit the client to labor and delivery
c. Check the client’s blood pressure, and if it is within normal limits, allow her to go home
d. Check the client’s complete blood count and notify the healthcare provider if the WBC is elevated
13. A client rec a Rx for 0.9% sodium chloride, USP 2 L IV to be infused over 24 hr. The IV administration set delivers 15gtt/ML. How many gtt/min should the RN regulate the infusion. (Numerical value, if rounding is required round to the nearest whole #) Answer: 21
14. An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as the result of cerebrovascular accident (CVA). which action should the nurse include in the plan of care?
a. Teach the client to turn his head from side to side for visual scanning
b. Provide additional light in the room to promote sensory stimulation
c. Place a clock and calendar in the room to improve orientation
d. Use hand and arm gesture to improve communication and comprehension
15. When prepping for a bone marrow aspiration, the nurse should place the client in which position to ensure access of the aspiration site?
a. Sitting up and leaning across at the over bed table
b. Supine with a pillow under the lumbar area
c. Prone with the posterior ilac crest draped
d. Side lying with the post chest exposed
16. A child who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has a 35% of personal best peak expiratory flow rate (PEFR). BAsed on these findings which action should the nurse implement first?
a. Encourage the child to cough and deep breathe
b. Determine what triggers precipitated this attack
c. Report findings to the healthcare provider
d. Administer a prescribed bronchodilator
17. When planning care for a client with acute pancreatitis, which nursing intervention is the highest prority?
a. Eval I&O
b. Withhold food and fluid intake
c. Intiatie IV fluid replacement
d. Admin antiemetics as needed
18. A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50mL/hour. The client’s urine specific gravity is 1.035. What action should the nurse implement?
a. Assess bowel sounds in all quadrants
b. Encourage popsicles and fluids of choice
c. Obtain a specimen for urinalysis
d. Evaluate postural blood pressure measurements
19. A client with anxiety does not want to communicate w/ friends, worries excessively, and reports not being able to deal with life. Which coping strat should the nurse include in the POC?
a. Relax and reduce the amt of effort to solve the problem
b. Practice switching thoughts to happy events in the past
c. Focus on small achievements not taxing problems
d. Concentrate on and ventilate emotions when distressed
20. A client with a 6 cm thoracic aneurysm is being prepared for surgery. The nurse reports to the heathcare provider that the client’s blood pressure is 220/112 mmHg, so anantihypertensive agent is added to the client’s IV infusion. Which finding warrants immediate intervention by the nurse?
a. BP readings of 200/100 mmHg 15 minutes later
b. Rose colored urine draining from the urinary catheter
c. Sinus tachycardia with frequent premature ventricular beats (PVC)
d. Reports a tearing, sharp pain between shoulder blades
21. The HCP prescribes the antibiotic celdnir 300 mg PO every 12hrs for a client with postop wound infection. Which foods should the RN encourage the client to eat?
a. Yogurt or buttermilk
b. Avocados and cheese
c. Green leafy veggies
d. Fresh Fruites
22. A client who is 32 weeks gestation is seen in the emergency department reporting vision changes. The nurse observes the client has also experienced a rapid weight gain over six weeks. Which action should the nurse implement next?
a. Check pupils for reactivity
b. Auscultate fetal heart tones
c. Obtain a blood pressure
d. Collect a finger stick glucose
23. A client dx with Raynaulds disease lives alone. Which instruction should the nurse include in the clients discharge teaching plan?
a. Wear TED stockings at night
b. Keep room temp at 80F (27.7C)
c. Hire a care-giver for 8hrs daily
d. Develop a walking exercise routine
24. A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?
a. A client at 28-weeks gestation in pre-term labor
b. A client who is leaking clear fluid
c. A mother who just delivered a 9 pound baby boy
d. A mother with an infected episiotomy
25. The HCP prescribes chloride 25 mEq in 500 ml D3W to infuse over 6 hours. The available 20 mL vial of potassium chloride is labeled “10 mEq 5 mL” How many mL of potassium chloride should the nurse add to the IV fluid?(Numeric value, if required round to the nearest tenth) Answer: 12.5
26. An adolescent male client is admitted to the hospital. Based on Erikson’s theory of psychosocial development, which nursing intervention best assists this adolescent’s adjustment to his hospital stay?
a. Provide access to a variety of video games in his room
b. Schedule frequent private phone calls to his parents
c. Encourage him to learn this way around the hospital
d. Invite him to participate in the evening group activity
27. The nurse is conducting a physical assessment. In examining the clients eyes, which client complaint should be reported to the HCP immediately?
a. A black hole in the center of the clients vision
b. A curtain coming across the clients vision today
c. Decrease peripheral vision for a year
d. Yellow, watery drainage from 1 eye
28. A (f) client rec a Rx for alendronate sodium to treat her newly dx osteoporosis. Which instruction should the nurse include in the clients teaching plan?
a. Take on an empty stomach with a full glass of water
b. Eat with 30 mins of taking the meds
c. Consume a light snack with the meds
d. Ingest an antacid 30m prior to taking the med
29. 18 y/o female client is seen at the health dept for tx of condylomata acuminata (perianal warts) caused by HPV. Which intervention should the nurse implement?
a. Recommend the use of latex condoms to prevent HPV transmission
b. Inform the client that warts do not return following cryo therapy
c. Tell the client that the vaccine for HPV is not indicated
d. Reinforce the importance of annual PAP smears
30. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non English-speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and interpreter speak together in the foreign language for an additional two minutes until the interpreter concludes, “She says it is OK.” What action should the nurse take next?
a. Have the interpreter co-sign the consent to validate client understanding
b. Clarify the client's consent through the use of gestures and simple
terms
c. Have the client sign the consent and the nurse witness the signature
d. Ask for a full explanation from the interpreter of the witnessed discussion
31. Prior to surgery written consent must be obtained. Which is the RNs legal responsibility with regard to obtaining written consent
a. Ask the client or fam member to sign the surgical consent form
b. Determine that the surgical consent form has been signed and is included in the clients record
c. Validate the clients understanding of the surg procedure to be conducted
d. Explain the surg procedure to the client and aks the client to sign the consent form
32. Which info is most important for the nurse to obtain when determining a clients risk for obstructive sleep apnea syndrome (OSAS)?
a. BMI
b. Self-description of pain
c. Breath sounds
d. LOC
33. A client is admitted with Hep A (HAV) and dehydration. Subjective sxs include anorexia, fatigue, and malaise. What additional assessment should the nurse expect to find during the preicteric phase?
a. Icteric sclera
b. Clay colored stool
c. Right Upper Quad ab pain
d. Pruitus
34. Which intervention should the nurse Implement when beginning a physical assessment of a six-month-old infant ?
a. Allow the child to remain sitting in the caretaker's lap.
b. Direct the caretaker to place the infant supine in the crib.
c. Suggest that the caretaker stand at the foot of the exam table.
d. Instruct the caretaker to place the infant on the exam table.
35. The nurse is triaging several kids as they present to the ER after a school bus accidnet. Which one requires the most immediate interventionby the RN?
a. 11 y/o w/ a headache, nasua, and projectile vomiting
b. 8 y/o w/ a full leg air splint for a possible broken tibia
c. 12 y/o reporting neck, arm, and lower back pain
d. 6 y/o with mult superficial lacerations of all extremities
36. A male client is admitted to the hospital with a medical dx of peptic ulcers. The nurse should inform the client that he is most likely to experience the greates pain and discomfort in what situaiton/?
a. When stomach is full
b. When stomach is empty
c. After consuming an extremely cold beverage
d. After consuming a high fat meal
37. A child w/ heart failure (HF) is taking digitalis. Which sign indicates to the RN that the child may be experiencing digitalis toxicity?
a. Muscle cramps
b. Dyspnea
c. Vomiting
d. Tachycardia
38. The Nurse enters the room of a disoriented (F) client to supervise the care being provided by an UAP. The UAP has left the room to obtain linens, leaving the client supine and lying on wet sheets, with the side rails down and the bed in high position. Which action should the nurse implement first?
a. Explain the risks of the unsafe situation to the UAP
b. Both upper side rails of the bed should be raised
c. Plae the client in a lat position off the wet linens
d. The client should be re oriented to her surroundings
39. During a woman’s health fair, which assignment is best for the practical nurse (PH) who is working with a RN?
a. Prep a woman for a bone density screening
b. Encourage woman at risk for cancer to obtain a colonoscopy
c. Present a class on breast self exam
d. Explaing the f/u needed for a client with prehypertension
40. A client hospitalized and recently dx with addisons disease is now confused and lethargic. Which actions should the nurse implement? (SATA)
a. Initiate fall risk precautions
b. Reduce rate of IV fluid infusion
c. Withhiold next dose of corticosteroid
d. Measure capillary glucose level
e. Monitor cardiac telemetery pattern
41. A client with MS is rec beta-1B interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum lab values should the nurse monitor? (SATA)
a. Sodium and potassium
b. WBC
c. Platelet count
d. Albumin and protein
e. RBC
42. A client who had a lung biopsy asks the nurse to explain the HCP report that the lung cancer is staged at T2N0M0 lung cancer. What information should the nurse provide?
a. Staging indicates the treatment options for surgery, radiation, or chemotherapy.
b. The client's understanding of the cancer's prognosis and quality of life.
c. The cancer is within its primary site with no lymph node or metastasis present.
d. The cancer has spread to other organs which limits the success rate of treatment.
43. The nurse assesses a full term infant whose mother has type 1 DM. The infants blood glucose level at 1 hour of age is 45 mg/dl (2.5 mmol/L) and at 2 hours of age it is 25 mg/dL (1.4 mmol/L). What is the cause of the chang in the blood glucose?
a. A normal, physical response of the body that occurs during transition from intrauterine to extrauterine life
b. An increase in urine production that results when the kidneys are ridding the body of excess glucose
c. A rxn to the stress of labor and the period of increased activity following delivery
d. A interruption in the source of glucose and continued highinsulin production by the infant
44. The nurse and client are discussing strategies to manage the client's acute pain following an injury. When setting goals, which information is most important for the nurse to obtain from the client?
a. Desired level of physical mobility.
b. Acceptable level of pain intensity.
c. Past experience with acute pain.
d. Cultural values related to pain.
45. A preschool teacher notifies the school nurse that child A has bitten child B on the arm. Child B’s skin is broken, but not bleeding. What action should the school nurse take first?
a. Determine if child A has a hx of Hep C or HIV
b. Apply antibiotic cream to Child Bs arm immediately
c. Determine the dae of Child b’s latest tetanus booster
d. Wash child B’s arm thoroughly with soap and water
46. The nurse is planning to implement a tuberculosis screening program at a community health clinic. What technique should the nurse use to screen clients who are non compromised?
a. Purified protein derivative ( PPD) skin test.
b. Stain sputum smear.
c. Culture tubercle bacilli.
d. Anterior view of a bilateral chest x-ray.
47. A postpartal client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide
the client?
a. Express a small amt of breast milk by hand
b. Place warm packs on both of the breast
c. Avoid stimulation of the breasts and wear a light bra
d. Take a prescribed analgesic and expose breast to air
48. The family of an older woman reports that they are no longer capable of caring for her at home. While performing the admission assessment at a long-term care facility, the nurse determines that the client is incontinent of urine, has dry mucous membranes, and has a large bruise on her coccyx. Which interventions should the nurse include in the plan of care? (SATA)
a. Report suspicion of elder abuse.
b. Thicken liquids and provide pureed foods.
c. Apply a barrier cream to perianal areas.
d. Offer beverages at frequent intervals.
e. Implement toileting program.
49. Following breakfast, the nurse is prepping to administer 0900 meds to a client on a medical floor. Which medshould be held until later
a. The loop diuretic furosemide for a client with a serum potassium level of 4.2 mEq
b. The mucosal barrier, sucralfate for a client dx with PUP
c. The antifungal med nystatin suspension for a client who has just brushed his teeth
d. The antiplatelet agent aspirin, for a client who is sch to be discharged within the hour
50. A client is hospitalized after experiencing a myocardial infarction. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
a. Assist with ambulation in the hallway.
b. Encourage active range of motion exercises.
c. Teach to sleep in a side-lying position.
d. Provide a bedside commode for toileting. [Show Less]