PN Hesi Exit V1
Question 1
A school-age client with diabetes is placed on an intermediateacting insulin and regular insulin before breakfast and
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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 laborand-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 demonstrates correct principles of confidentiality?
You Selected:
• Two nurses alone in an elevator are discussing a client's
status.
Correct response:
• An emergency department nurse reports suspected child
abuse.
Question 29
The nurse in a psychiatric unit has formed a therapeutic relationship
with a client with a borderline personality disorder. When the client
is readmitted to the unit for a suicide attempt, the nurse exclaims to
another staff nurse, “Why? Everything was going well. How could
they do this to me?” What response by the staff nurse reflects an
understanding of the client’s borderline disorder?
You Selected:
• “Clients with borderline disorder act out to relieve anxiety,
and something must have provoked a great deal of anxiety.”
Correct response:
• “Clients with borderline disorder act out to relieve anxiety,
and something must have provoked a great deal of anxiety.”
Question 30
A child is receiving total parenteral nutrition (TPN). During TPN
therapy, the most important nursing action is:
You Selected:
• monitoring the blood glucose level closely.
Correct response:
• monitoring the blood glucose level closely.
Question 31
A 9-year-old client is brought to the emergency department with a
sutured wound with purulent drainage. The area around the wound
is red and warm to the touch, and the child is febrile. The parents
want to know the significance of the purulent drainage. What is
the best response by the nurse?
You Selected:
• “The drainage is an indication that the sutures were not tight
enough.”
Correct response:
• “If a wound heals on the surface but infection remains, it will
open and drain.”
Question 32
A 19-year-old primigravid client at 38 weeks' gestation is 7 cm
dilated, and the presenting part is at +1 station. The client tells the
nurse, "I need to push!" What should the nurse do next?
You Selected:
• Instruct the client to use a pant-blow pattern of breathing.
Correct response:
• Instruct the client to use a pant-blow pattern of breathing.
Question 33
A client with cystic fibrosis develops pneumonia. To decrease the
viscosity of respiratory secretions, the physician orders
acetylcysteine. Before administering the first dose, the nurse checks
the client's history for asthma. Acetylcysteine must be used
cautiously in a client with asthma because it
You Selected:
• may induce bronchospasm.
Correct response:
• may induce bronchospasm.
Question 34
Bone resorption is a possible complication of Cushing’s disease. To
help the client prevent this complication, what should the nurse
recommend to the client?
You Selected:
• Maintain a regular program of weight-bearing exercise.
Correct response:
• Maintain a regular program of weight-bearing exercise.
Question 35
A client rates the pain level of a migraine an 8 on a scale of 1-10.
How would the nurse administer the medication to give the client
the quickest relief?
You Selected:
• intravenous (IV)
Correct response:
• intravenous (IV)
Question 36
A client with Parkinson’s disease w [Show Less]