HESI EXIT TEST BANK V1-V3 QUESTIONS AND
100%CORRECT ANSWERS A + GRADED
HESI EXIT Test Bank V1
Following a motor vehicle collision, an adult female with a ruptured spleen and a blood
pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her
urine output is 25 ml/hour for the last two hours. What pathophysiological reason
supports the nurse's decision to report this finding to the healthcare provider? --
CORRECT ANSWER-Oliguria signals tubular necrosis related to hypoperfusion
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing
formula based on what data ensures quality client care and is most cost-effective? --
CORRECT ANSWER-Skills of staff and client acuity
When performing postural drainage on a client with Chronic Obstructive Pulmonary
Disease (COPD), which approach should the nurse use? -- CORRECT ANSWER-
Explain that the client may be placed in five positions
A client presents in the emergency room with right-sided facial asymmetry. The nurse
asks the client to perform a series of movements that require use of the facial muscles.
What symptoms suggest that the client has most likely experience a Bell's palsy rather
than a stroke? -- CORRECT ANSWER-Inability to close the affected eye, raise brow, or
smile
The nurse is teaching a client how to perform colostomy irrigations. When observing the
client's return demonstration, which action indicated that the client understood the
teaching? -- CORRECT ANSWER-Keeps the irrigating container less than 18 inches
above the stoma
The nurse should teach the client to observe which precaution while taking
dronedarone? -- CORRECT ANSWER-Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is admitted to the
hospital. The nurse include the client's risk for developing increased intracranial
pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has
increased? -- CORRECT ANSWER-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of increased ICP, and confusion is usually
the first sign of
increased ICP. Other options do not necessarily reflect increased ICP.
,The nurse is caring for a client receiving continuous IV fluids through a single lumen
central venous catheter (CVC). Based on the CVC care bundle, which action should be
completed daily to reduce the
risk for infection? -- CORRECT ANSWER-Confirm the necessity for continued use of
the CVC.
During an annual physical examination, an older woman's fasting blood sugar (FBS) is
determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during
a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus
(DM)? -- CORRECT ANSWER-Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4
mmol/L (SI).
A client who was admitted yesterday with severe dehydration is complaining of pain a
24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention
should the nurse implement first? -- CORRECT ANSWER-Stop the normal saline
infusion.
An elderly female is admitted because of a change in her level of sensorium. During the
evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's
skin traction is applied to the left leg while waiting for surgery. Which intervention is
most important for the nurse to include in this client's plan care? -- CORRECT
ANSWER-Ensure proper alignment of the leg in traction.
A client who had a right hip replacement 3 day ago is pale has diminished breath sound
over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate
of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF)
tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what
recommendation should the nurse give the healthcare provider? -- CORRECT
ANSWER-Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
prescription for metformin (Glucophage) 500 mg PO twice daily. What information
should the nurse include in this client's teaching plan? (Select all that apply.) --
CORRECT ANSWER-Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
The nurse is developing an educational program for older clients who are being
discharged with new antihypertensive medications. The nurse should ensure that the
educational materials include which
characteristics? Select all that apply -- CORRECT ANSWER-Written at a twelfth grade
reading level
,Contains a list with definitions of unfamiliar terms
Uses common words with few Syllables
Printed using a 12 point type font
Uses pictures to help illustrate complex ideas
Rationale: During the aging process older clients often experience sensory or cognitive
changes, such as
decreased visual or hearing acuity, slower thought or reasoning processes, and shorter
attention span.
Materials for this age group should include at least of terms, such as a medical
terminology that incline
may not know and use common words that expresses information clearly and simply.
Simple, attractive
pictures help hold the learner's attention. The reading level of material should be at the
4th to 5th grade
level. Materials should be printed using large font (18-point or higher), not the standard
12-point font.
During the admission assessment, the nurse auscultates heart sounds for a client with
no history of cardiovascular disease. Where should the nurse listen when assessing the
client's point of maximal
impulse (PMI) (Click the chosen location. To change, click on a new location) --
CORRECT ANSWER-Left Fourth Intercostal Space
An older male adult resident of long-term care facility is hospitalized for a cardiac
catheterization that occurred yesterday. Since the procedure was conducted, the client
has become increasingly disoriented. The night shift nurse reports that he attempted to
remove the sandbag from his femoral artery multiple times during the night. What
actions should the nurse take? (Select all that apply.) -- CORRECT ANSWER-Notify the
healthcare provider of the client's change in mental status.
Include q2 hour's reorientation in the client's plan of care.
An older male comes to the clinic with a family member. When the nurse attempts to
take the client's health history, he does not respond to questions in a clear manner.
What action should the nurse
implement first? -- CORRECT ANSWER-Assess the surroundings for noise and
distractions.
The nurse caring for a client with acute renal fluid (ARF) has noted that the client has
voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse
anticipate that client will need? -- CORRECT ANSWER-Large amounts of fluid and
electrolyte replacement.
, Which intervention should the nurse include in the plan of care for a child with tetanus? -
- CORRECT ANSWER-Minimize the amount of stimuli in the room
Suicide precautions are initiated for a child admitted to the mental health unit following
an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of
cigarettes in the client's room.
Which intervention is most important for the nurse to implement? -- CORRECT
ANSWER-Remove cigarettes for the client's room
A family member of a frail elderly adult asks the nurse about eligibility requirements for
hospice care.
What information should the nurse provide? (Select all that apply.) -- CORRECT
ANSWER-A client must be willing to accept palliative care, not curative care.
The healthcare provider must project that the client has 6 months or less to live.
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction
should the nurse include in this client's teaching plan? -- CORRECT ANSWER-Avoid
use of nonsteroidal ant-inflammatory drugs (NSAID).
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? --
CORRECT ANSWER-A mother with an infected episiotomy
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is
irritable and diaphoretic with jugular vein distention. Which prescription should the nurse
administer first? -- CORRECT ANSWER-Digoxin.
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse
(PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse
assign to the RN? -- CORRECT ANSWER-Supervise a newly hired graduate nurse
during an admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed asthma,
the client stares into the distance and appears to be concentrating on something other
than the lesson the nurse is
presenting. What action should the nurse take? -- CORRECT ANSWER-Ask the client
what he is thinking about at his time.
After several hours of non-productive coughing, a client presents to the emergency
room complaining of chest tightness and shortness of breath. History includes end
stage chronic obstructive pulmonary
disease (COPD) and diabetes mellitus. While completing the pulmonary assessment,
the nurse hears wheezing and poor air movement bilaterally. Which actions should the
100%CORRECT ANSWERS A + GRADED
HESI EXIT Test Bank V1
Following a motor vehicle collision, an adult female with a ruptured spleen and a blood
pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her
urine output is 25 ml/hour for the last two hours. What pathophysiological reason
supports the nurse's decision to report this finding to the healthcare provider? --
CORRECT ANSWER-Oliguria signals tubular necrosis related to hypoperfusion
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing
formula based on what data ensures quality client care and is most cost-effective? --
CORRECT ANSWER-Skills of staff and client acuity
When performing postural drainage on a client with Chronic Obstructive Pulmonary
Disease (COPD), which approach should the nurse use? -- CORRECT ANSWER-
Explain that the client may be placed in five positions
A client presents in the emergency room with right-sided facial asymmetry. The nurse
asks the client to perform a series of movements that require use of the facial muscles.
What symptoms suggest that the client has most likely experience a Bell's palsy rather
than a stroke? -- CORRECT ANSWER-Inability to close the affected eye, raise brow, or
smile
The nurse is teaching a client how to perform colostomy irrigations. When observing the
client's return demonstration, which action indicated that the client understood the
teaching? -- CORRECT ANSWER-Keeps the irrigating container less than 18 inches
above the stoma
The nurse should teach the client to observe which precaution while taking
dronedarone? -- CORRECT ANSWER-Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is admitted to the
hospital. The nurse include the client's risk for developing increased intracranial
pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has
increased? -- CORRECT ANSWER-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of increased ICP, and confusion is usually
the first sign of
increased ICP. Other options do not necessarily reflect increased ICP.
,The nurse is caring for a client receiving continuous IV fluids through a single lumen
central venous catheter (CVC). Based on the CVC care bundle, which action should be
completed daily to reduce the
risk for infection? -- CORRECT ANSWER-Confirm the necessity for continued use of
the CVC.
During an annual physical examination, an older woman's fasting blood sugar (FBS) is
determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during
a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus
(DM)? -- CORRECT ANSWER-Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4
mmol/L (SI).
A client who was admitted yesterday with severe dehydration is complaining of pain a
24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention
should the nurse implement first? -- CORRECT ANSWER-Stop the normal saline
infusion.
An elderly female is admitted because of a change in her level of sensorium. During the
evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's
skin traction is applied to the left leg while waiting for surgery. Which intervention is
most important for the nurse to include in this client's plan care? -- CORRECT
ANSWER-Ensure proper alignment of the leg in traction.
A client who had a right hip replacement 3 day ago is pale has diminished breath sound
over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate
of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF)
tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what
recommendation should the nurse give the healthcare provider? -- CORRECT
ANSWER-Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
prescription for metformin (Glucophage) 500 mg PO twice daily. What information
should the nurse include in this client's teaching plan? (Select all that apply.) --
CORRECT ANSWER-Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
The nurse is developing an educational program for older clients who are being
discharged with new antihypertensive medications. The nurse should ensure that the
educational materials include which
characteristics? Select all that apply -- CORRECT ANSWER-Written at a twelfth grade
reading level
,Contains a list with definitions of unfamiliar terms
Uses common words with few Syllables
Printed using a 12 point type font
Uses pictures to help illustrate complex ideas
Rationale: During the aging process older clients often experience sensory or cognitive
changes, such as
decreased visual or hearing acuity, slower thought or reasoning processes, and shorter
attention span.
Materials for this age group should include at least of terms, such as a medical
terminology that incline
may not know and use common words that expresses information clearly and simply.
Simple, attractive
pictures help hold the learner's attention. The reading level of material should be at the
4th to 5th grade
level. Materials should be printed using large font (18-point or higher), not the standard
12-point font.
During the admission assessment, the nurse auscultates heart sounds for a client with
no history of cardiovascular disease. Where should the nurse listen when assessing the
client's point of maximal
impulse (PMI) (Click the chosen location. To change, click on a new location) --
CORRECT ANSWER-Left Fourth Intercostal Space
An older male adult resident of long-term care facility is hospitalized for a cardiac
catheterization that occurred yesterday. Since the procedure was conducted, the client
has become increasingly disoriented. The night shift nurse reports that he attempted to
remove the sandbag from his femoral artery multiple times during the night. What
actions should the nurse take? (Select all that apply.) -- CORRECT ANSWER-Notify the
healthcare provider of the client's change in mental status.
Include q2 hour's reorientation in the client's plan of care.
An older male comes to the clinic with a family member. When the nurse attempts to
take the client's health history, he does not respond to questions in a clear manner.
What action should the nurse
implement first? -- CORRECT ANSWER-Assess the surroundings for noise and
distractions.
The nurse caring for a client with acute renal fluid (ARF) has noted that the client has
voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse
anticipate that client will need? -- CORRECT ANSWER-Large amounts of fluid and
electrolyte replacement.
, Which intervention should the nurse include in the plan of care for a child with tetanus? -
- CORRECT ANSWER-Minimize the amount of stimuli in the room
Suicide precautions are initiated for a child admitted to the mental health unit following
an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of
cigarettes in the client's room.
Which intervention is most important for the nurse to implement? -- CORRECT
ANSWER-Remove cigarettes for the client's room
A family member of a frail elderly adult asks the nurse about eligibility requirements for
hospice care.
What information should the nurse provide? (Select all that apply.) -- CORRECT
ANSWER-A client must be willing to accept palliative care, not curative care.
The healthcare provider must project that the client has 6 months or less to live.
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction
should the nurse include in this client's teaching plan? -- CORRECT ANSWER-Avoid
use of nonsteroidal ant-inflammatory drugs (NSAID).
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? --
CORRECT ANSWER-A mother with an infected episiotomy
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is
irritable and diaphoretic with jugular vein distention. Which prescription should the nurse
administer first? -- CORRECT ANSWER-Digoxin.
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse
(PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse
assign to the RN? -- CORRECT ANSWER-Supervise a newly hired graduate nurse
during an admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed asthma,
the client stares into the distance and appears to be concentrating on something other
than the lesson the nurse is
presenting. What action should the nurse take? -- CORRECT ANSWER-Ask the client
what he is thinking about at his time.
After several hours of non-productive coughing, a client presents to the emergency
room complaining of chest tightness and shortness of breath. History includes end
stage chronic obstructive pulmonary
disease (COPD) and diabetes mellitus. While completing the pulmonary assessment,
the nurse hears wheezing and poor air movement bilaterally. Which actions should the
