HESI RN Final EXIT Exam| 2023/ 2024| 180
Questions and 100% Correct Verified
Answers with Rationales| Complete Solution
QUESTION
A client
... [Show More] receives an IV heparin infusion at 22 mL/hr through an infusion pump. The IV bag
contains 25,000 units of heparin in 500 mL of 5% dextrose in water. How many units of heparin
is the client receiving during an 8-hour shift?
Calculate and record the answer in the box.
Your Response:
Correct Response: 8800
units
50 units heparin/1 mL
50 units x 22 = 1100 units per hour
1100 units x 8 = 8800 units heparin
QUESTION
The nurse teaches a client who had an above-knee amputation (AKA) 2 days ago about how to
care for the residual limb. Which statement, if made by the client, indicates to the nurse that the
teaching is effective?
1. "I shall apply cream to the residual limb to soften the skin."
2. "I should rewrap my residual limb with elastic bandages 3 times a day."
3. "I will not be able to sleep on my stomach from now on."
4. "I will no longer be able to sit in straight back chairs at home."
1) Implementation: outcome not desired; skin needs to be toughened if prosthesis is going to be
used; no lotions, creams, or powders should be used unless prescribed
2) Answer: Implementation: outcome desired; bandages may be loose; expose to air 20 min/day;
inspect residual limb for redness, irritation
3) Implementation: outcome not desired; the prone position will decrease the risk of flexion
contractures
4) Implementation: outcome not desired; client can sit in straight back chair; time should be
restricted to 1 hour or less
QUESTION
The husband of an elderly client who is incontinent asks the nurse whether his wife will have to
wear diapers. Which response, if made by the nurse, is MOST appropriate?
1. "Let's discuss your specific concerns about your wife."
2. "Have you tried any type of incontinence pads in the past?"
3. "Let's wait and see if incontinence pads are necessary."
4. "There are many brands of adult diapers available for you to try."
1) Answer: Outcome desired; open-ended; client can verbalize concerns
2) Outcome not priority; need to address husband's immediate concerns; is "yes/no" answer
3) Outcome not desired; need to deal with the "here and now"
4) Outcome not desired; non-therapeutic; dismisses concerns
QUESTION
The school nurse teaches accident-prevention to the parents of school-aged children. Which
statement, if made by a parent to the nurse, indicates teaching is effective?
1. "I'm going to make sure my child wears a helmet, shin guards, and gloves when he rides his
bike."
2. "I keep my guns and ammunition in a locked cabinet in the basement."
3. "The next time we go to the park, I'm going to teach my child the correct way to climb on the
monkey bars."
4. "I'm going to make sure my wife and I observe our child when he plays outside with friends."
1) Implementation: outcome not desired; only bicycle helmet is recommended; additional
protective gear with skateboarding or rollerblading
2) Implementation: outcome not desired; guns and ammunition should be kept in separate locked
areas
3) Answer: Implementation: outcome desired; injury prevention facilitated by age-appropriate
safety education
4) Implementation: outcome not desired; school-aged children are developmentally ready for less
supervision; parents should encourage interaction with peers
QUESTION
The nurse cares for a client who had a Roux-en-Y gastric bypass procedure 4 hours ago. The
client's vital signs are blood pressure 92/68, apical heart rate 112 per minute, and respiratory rate
22 per minute. Which order should the nurse question?
1. 0.9% sodium chloride water infusion at 150 mL/hour.
2. Epinephrine (Adrenalin) 1 mg bolus intravenously.
3. Monitor urinary output hourly for 24 hours.
4. 50 mL 25% albumin (human) 50 mL intravenously.
1) Implementation: outcome desired; is isotonic; will replace lost blood volume
2) Answer: Implementation: outcome not desired; effect is vasoconstriction with further
decrease of blood flow to vital organs; used to treat anaphylactic shock
3) Implementation: outcome desired; measuring urinary output meaures renal perfusion;
appropriate activity
4) Implementation: outcome desired; is a crystalloid; will expand plasma volume rapidly; must
carefully monitor response
QUESTION
A nurse from the surgical floor is reassigned to the pediatric unit. Which of the following client
assignment is MOST appropriate for this nurse?
1. A 5-month-old infant after a cast application on the left extremity due to club foot.
2. A 4-year-old boy with right abdominal swelling and a decreased appetite.
3. A 6-year-old boy admitted with cystic fibrosis and a temperature of 101.5 F (38.68 C).
4. A 10-year-old girl with newly diagnosed type 1 diabetes.
He [Show Less]