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Version 3
HESI Exit Exam
| Question | Answer |
|---|---|
| A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blo | d. Increase the infusion rate of Lactated Ringer's solution. |
| An adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suc | A. Add sterile water to the suction control chamber |
| A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen | c. Begin supplemental oxygen |
| A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation. Based on the client’s admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) 1. Headache and tremors 2. Irr | 1. Headache and tremors 2. Irregular heart rate 5. Pallor and diaphoresis |
| An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? a. Urine specific gravity is 1.040 b. Systolic blood pressure | d. Skin tenting occurs when the client’s forearm is pinched. |
| After an in-service about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? a. Fi | a. File a report with the specific hiring facility. |
| The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective? a. At-risk clients received an increased number of routine health scre | c. Clients who incurred disease complications promptly received rehabilitation |
| The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths | d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula. |
| Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? a. “When I get out of bed quickly, I feel a little dizzy.” b. “The dressing over my incision feels like it is too tight.” c. | a. “When I get out of bed quickly, I feel a little dizzy.” |
| An older adult male who is in his early 70’s is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe, and the healthcare team is preparing for endotracheal intubation. The spouse’s wife, who is 30 y | b. Notify the provider of the client’s wishes. |
| An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assis | a. Determine the client’s level of mobility and need for assistance. |
| A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at the parent-teacher meeting. What action is most important for the nurse to include in the meeting? a. Provide information | a. Provide information on ways to increase activity for the family. |
| After several months of chronic fatigue, morning stiffness, and joint pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to ta | c. If sequential doses are missed, notify the healthcare provider |
| The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse’s immediate attention? a. A 16-year-old client diagnosed with major depression who refuses to participate in group. b. A 14-year-old client with anore | c. An 18-year-old client with antisocial behavior who is being yelled at by other clients |
| The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms? a. Positive Epstein-Barr, and malaise. b. Ear pain and fever. c. Elevated WBC and sedimentation rate. d. Increased BUN and serum creatinine. | b. Ear pain and fever. |
| A client arrives for an annual physical exam and complains of having calf pain. The client’s health history reveals peripheral atrial disease. Which question should the nurse ask the client about expected finding related to chronic arterial symptoms? | b. Does the calf pain occur when walking short distances? |
| The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure? a. Drank a glass of water in the past 2 hours. b. R | d. Experience facial swelling after eating crab. |
| The nurse is assessing a 4-year-old child with eczema. The child’s skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of thi | a. Keep the nails trimmed short. |
| A new mother on the postpartum unit runs out of the room screaming that her newborn infant’s crib is empty, and the baby is missing. What action should the nurse take first? a. Determine if the newborn is in the nursery. b. Activate the lockdown pro | a. Determine if the newborn is in the nursery. |
| While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? a. “Do you often have feeling of sadness?” b. “Are you having problems | c. “Have you thought about taking your life?” |
| A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, “kill, kill.” What question should the nurse ask the client next? | c. “Are you planning to obey the voices?” |
| The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? a. The client will express | d. The client’s skin on the lower legs will be intact at the next clinical visit. |
| When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (select all that apply.) a. Fruits without sauce b. Canned soup. c. Fresh or frozen vegetables without sauce | a. Fruits without sauce c. Fresh or frozen vegetables without sauce |
| A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse that the client is experiencing a therapeutic response to the phenytoin? a. Increased time of ambulation between periods of rest. b. Decrease | c. Absence of seizure activity for the duration of treatment. |
| The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all that apply) a. Brings a heavy can close to body befo | a. Brings a heavy can close to body before lifting. c. Widens stance while working near the sink. |
| An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative i | b. Reduce environmental stimuli |
| The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)? a. Measure the client’s body weight each morning. b. Establish blood for parameters for client | a. Measure the client’s body weight each morning. |
| During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first? a. The census report has not been completed. b. A client’s wife has asked to speak with the charge nurse. c. One staff member | d. A bucket of water was spilled in the hallway. |
| An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview? a. History o | d. recent compliance with prescribed medications. |
| The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? a. Assess the client’s oral cavity for u | d. Request thick nectar liquids for the client. |
| A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement? a. Bring a bedside commode to the client. b. Stand on the client’s right side as he walks. c. Walk directly behin | b. Stand on the client’s right side as he walks. |
| An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to imp | b. Ensure that the client is assigned to a room close to the nurses’ station. |
| The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client’s plan of care? a. Ensure adequate IV and oral fluid intake. b. Provide ice packs to major joint areas. c. Space analges | a. Ensure adequate IV and oral fluid intake. |
| The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of preeclampsia and should be reported to the healthcare provider? (Select all that apply.) a. Blurred vision b. headache c. Lack of appetite d. urinary freque | a. Blurred vision b. headache F. Swollen hands. |
| A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? a. Suggest the nurse use a 20-gauge needle. b. Direct the nurse to change the IV tubing. c. Instruct the nurs | c. Instruct the nurse to remove the needle. |
| A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? a. Initiate seizure pr | a. Initiate seizure precautions |
| The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900, what nursing action is most important? a. Confirm that the client has been NPO since midnight. b. Review postoperative inst | a. Confirm that the client has been NPO since midnight. |
| The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? a. Gradual onset of continuous eye pain and blurred vision. b. Recent change in the ability to read | a. Gradual onset of continuous eye pain and blurred vision. |
| A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? a. | d. Assist him in fast foods that are within his meal plan for diabetes. |
| A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting his illness and is only continuing treatments because his family wants him to live. Whi | c. Ask the chaplain to discuss death issues with the client. |
| Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing..... had a pulmonary embolus. What action should the nurse take first? a. Bring the emergency crash cart to the bedside. b. Prep | c. Provide supplemental oxygen |
| A client admitted with a liver abscess is scheduled for surgical evacuation and drainage of the abscess tomorrow morning. Nursing assesses .... Client’s abdominal pain has increased from 4 to 8 on a 10-pain scale in the last four hours. What is priori | a. Notify the surgeon of increasing abdominal pain. |
| A female client with chronic kidney disease and renal failure has an indwelling peritoneal catheter in used for peritoneal dialysis. While bathing, her abdominal dressing becomes wet. What action should the nurse take? a. Change the dressing. b. R | a. Change the dressing. |
| The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome shows a plan of care for this client? a. The client will express acceptance of his changing health status. b. The client’s | c. The nurse will demonstrate the procedure for accurate eye care. |
| The nurse identifies an electrolyte imbalance, an elevated pulse rate, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with chronic kidney disease. What intervention should the nurse include in the plan of care? a. Monitor serum electro | a. Monitor serum electrolytes daily. |
| A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room, or eat meals. In addition to patient’s safety, which short-term goal should the nurse include in the plan of care? a. Attends one group ac | d. Consumes 3 meals and 1500 mL of fluid per day. |
| Which information is a priority for the RN to reinforce to an older client after intravenous pyelogram? a. Eat a light diet for the rest of the day b. Rest for the next 24 hours since the preparation and the test is tiring. c. During waking hours dr | d. Measure the urine output for the next day and immediately notify the health care provider if it should decrease. |
| .A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is a. Difference in the intake and output b. Changes in the mucous membranes c. Skin | d. Weekly weight |
| A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client? a. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper par | b. It is critical to report promptly to your health care provider any findings of peptic ulcers |
| A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first? a. Check the protein level in urine b. Have the client turn to the | b. Have the client turn to the left side |
| The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? a. Diminished bowel sounds b. Loss of appetite c. | c. A cold, pale lower leg |
| The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A) Nausea and vo | B) Fever of 103 (39.5) |
| A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? a. Until the health care provider has determined that your ejaculation doesn’t contain sperm, con | a. Until the health care provider has determined that your ejaculation doesn’t contain sperm, continue to use another form of contraception. |
| A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? A)Some needles go as deep as 3 | C) The flow of life is believed to flow through major pathways or nerve clusters in your body. |
| The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? A) It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mout | C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent |
| A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-l | A) Side-lying on the left with the head elevated 10 degrees |
| A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? a.Light, pink urine b | c. minimal drainage into the urinary collection bag |
| A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse? A) Relieve the nu | C) Participate with the compressions or breathing |
| A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse? A) Relieve the nu | C) Participate with the compressions or breathing |
| The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar | B) Jugular vein distention |
| A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguri | A) Can predispose to dysrhythmias |
Created by:
SaiH
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