, HESI RN EXIT EXAM V3 ACTUAL EXAM (INET)-100% ACTUAL
PROCTORED EXAM, A+ Solutions
1.1A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
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nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 1 1
after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding
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to the surgeon. Which action should the nurse implement first?
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a. Measureand documentthe client’s urinary output. 11 11 1 11 11 11
b. Requestthe client’s reserved unitifpacked redbloodcells. 1 11 11 11 11 11 11 11 1
c. Prepare the placement of a central venous catheter. 11 1 1 1 1 11 1 1 11 1 1
d. Increasethe infusionrateofLactatedRinger’s solution. 1 11 1 11 1 1 11
2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right
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pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the
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intensive care unit (ICU).the nurse notes thatthe suction control chamber isbubbling at the
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
is measured in the collection chamber. Which intervention should the nurse implement?
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a. Addsterilewater to the suctioncontrol chamber. 11 1 11 11 11 1 11
b. Give bloodfromthe collectionchamber asautotransfusion 11 11 1 11 1 11 11
c. Manipulate bloodin tubing to draininto chamber. 11 1 11 11 11 1 1 1
d. Increasewall suctionto eliminate fluctuation inwater seal. 1 11 1 11 11 11 1 11
3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg,
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heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting
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shortness ofbreath, bilateral2+pedaledema, and an oxygensaturation onroomair of 89%. Which
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action should the nurse take first?
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a. Elevate the foot ofthe bed. 11 11 11 11 11
b. Restrict the client’s fluid. 1 1 1 1 1 1
c. Beginsupplementaloxygen. 1 1
d. Prepare the client for hemodialysis. 11 11 11 11
,4. A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation.
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Basedonthe client’s admitting diagnosis,whichfindings require immediate action by the nurse?
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(Select all that apply)
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a. Headache and tremors 11 11
b. Irregularheart rate 1 11
c. Skin hyperpigmentation 11
d. Posturalhypotension 1
e. Pallor and diaphoresis 11 11
5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is
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the best indicator of hydration that the nurse should report to the healthcare provider?
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a. Urinespecificgravity is1.040 11 11 11 11
b. Systolicbloodpressuredecreases10 pointswhenstanding. 1 1 1 1 11 1 1
c. The client denies beingthirsty. 11 11 11 11
d. Skintenting occurswhenthe client’sforearm ispinched. 1 11 11 1 11 1 11 11
6. After an inservice about electronic health record (EHR) security and safeguarding client
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information, the nurse observes a colleague going home with printed copies of client
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information in a uniform pocket. Which action should the nurse take?
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a. File a detailed incidentreportwiththe specifichiring facility.
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b. Warnthecolleague thattheir actions are unprofessional. 1 1 11 11 11 11 11
c. Comment anonymouslyaboutthe actionof a staffdiscussionboard. 11 1 11 11 1 11 11 1 1
d. Communicatethe colleague’s actions to theunit charge nurse. 1 11 11 11 11 1 11 11
, 7. The nurse isevaluating a tertiary prevention program for clients with cardiovascular disease
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implemented in a rural health clinic. Which outcome indicate the program is effective?
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a. At-riskclients received anincreasednumberofroutine healthscreenings.
1 11 11 1 1 1 1 11 1
b. Clientsreportedhaving new confidenceinmakinghealthy foodchoices.
1 1 11 11 1 1 1 11 1
c. Clientswhoincurreddiseasecomplicationspromptlyreceivedrehabilitation.
1 1 1 1 1 1 1
d. Clientrelapse rateof30% ina5-year community-wideanti-smokingcampaign.
1 11 1 1 11 11 1 11 1 11
8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses
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oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is
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having increased shortness of breath with respirations at 23 breaths/minute. Which action
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should the nurse implement first?
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a. Determine if theclientisexperiencing any anxiety. 11 11 1 11 1 11 11
b. Auscultatethe client’s bilateral lungsoundsandoxygensaturation. 1 11 11 11 11 11 1 1
c. Notifythe healthcare provider aboutthe client’sdistress.
1 11 11 11 1 11 11
d. Assessthe deliverymechanismofthe oxygen tank, tubing, andcannula.
1 11 11 1 1 11 11 11 11 11
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an
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immediate investigation by the nurse?
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a. “When I get out of bed quickly, I feel a little dizzy.” 11 11 11 11 11 11 11 11 11 11 11
b. “Thedressingovermy incision feelslike it is too tight.”
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c. “I’mmostcomfortable when the headofthe bed is raised.”
1 11 11 11 11 1 11 11 11 11
d. “ThisIV infusionmakesmeurinate moreoften than usual.”
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PROCTORED EXAM, A+ Solutions
1.1A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 1 1
after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
to the surgeon. Which action should the nurse implement first?
11 11 11 11 11 11 11 11 11 11
a. Measureand documentthe client’s urinary output. 11 11 1 11 11 11
b. Requestthe client’s reserved unitifpacked redbloodcells. 1 11 11 11 11 11 11 11 1
c. Prepare the placement of a central venous catheter. 11 1 1 1 1 11 1 1 11 1 1
d. Increasethe infusionrateofLactatedRinger’s solution. 1 11 1 11 1 1 11
2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
intensive care unit (ICU).the nurse notes thatthe suction control chamber isbubbling at the
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
is measured in the collection chamber. Which intervention should the nurse implement?
11 11 11 11 11 11 11 11 11 11 11 11
a. Addsterilewater to the suctioncontrol chamber. 11 1 11 11 11 1 11
b. Give bloodfromthe collectionchamber asautotransfusion 11 11 1 11 1 11 11
c. Manipulate bloodin tubing to draininto chamber. 11 1 11 11 11 1 1 1
d. Increasewall suctionto eliminate fluctuation inwater seal. 1 11 1 11 11 11 1 11
3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg,
11 11 11 11 11 11 11 11 11 11 11 11 11
heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting
11 11 11 11 11 11 11 11 11 11 11 11 11
shortness ofbreath, bilateral2+pedaledema, and an oxygensaturation onroomair of 89%. Which
11 11 11 11 1 11 1 11 11 11 11 11 11 1 11 11 11
action should the nurse take first?
11 11 11 11 11 11
a. Elevate the foot ofthe bed. 11 11 11 11 11
b. Restrict the client’s fluid. 1 1 1 1 1 1
c. Beginsupplementaloxygen. 1 1
d. Prepare the client for hemodialysis. 11 11 11 11
,4. A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation.
11 11 11 11 11 11 11 11 11 11 11 11
Basedonthe client’s admitting diagnosis,whichfindings require immediate action by the nurse?
11 11 11 11 11 11 11 11 11 11 11 11 11 11
(Select all that apply)
11 11 11 11
a. Headache and tremors 11 11
b. Irregularheart rate 1 11
c. Skin hyperpigmentation 11
d. Posturalhypotension 1
e. Pallor and diaphoresis 11 11
5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is
11 11 11 11 11 11 11 11 11 11 11 11 11 11
the best indicator of hydration that the nurse should report to the healthcare provider?
11 11 11 11 11 11 11 11 11 11 11 11 11 11
a. Urinespecificgravity is1.040 11 11 11 11
b. Systolicbloodpressuredecreases10 pointswhenstanding. 1 1 1 1 11 1 1
c. The client denies beingthirsty. 11 11 11 11
d. Skintenting occurswhenthe client’sforearm ispinched. 1 11 11 1 11 1 11 11
6. After an inservice about electronic health record (EHR) security and safeguarding client
11 11 11 11 11 11 11 11 11 11 11
information, the nurse observes a colleague going home with printed copies of client
11 11 11 11 11 11 11 11 11 11 11 11 11
information in a uniform pocket. Which action should the nurse take?
11 11 11 11 11 11 11 11 11 11 11
a. File a detailed incidentreportwiththe specifichiring facility.
11 11 11 1 11 11 11 1 11
b. Warnthecolleague thattheir actions are unprofessional. 1 1 11 11 11 11 11
c. Comment anonymouslyaboutthe actionof a staffdiscussionboard. 11 1 11 11 1 11 11 1 1
d. Communicatethe colleague’s actions to theunit charge nurse. 1 11 11 11 11 1 11 11
, 7. The nurse isevaluating a tertiary prevention program for clients with cardiovascular disease
11 11 11 11 11 11 11 11 11 11 11 11
implemented in a rural health clinic. Which outcome indicate the program is effective?
11 11 11 11 11 11 11 11 11 11 11 11 11
a. At-riskclients received anincreasednumberofroutine healthscreenings.
1 11 11 1 1 1 1 11 1
b. Clientsreportedhaving new confidenceinmakinghealthy foodchoices.
1 1 11 11 1 1 1 11 1
c. Clientswhoincurreddiseasecomplicationspromptlyreceivedrehabilitation.
1 1 1 1 1 1 1
d. Clientrelapse rateof30% ina5-year community-wideanti-smokingcampaign.
1 11 1 1 11 11 1 11 1 11
8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses
11 11 11 11 11 11 11 11 11 11 11 11 11 11
oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is
11 11 11 11 11 11 11 11 11 11 11 11 11 11 11
having increased shortness of breath with respirations at 23 breaths/minute. Which action
11 11 11 11 11 11 11 11 11 11 11 11
should the nurse implement first?
11 11 11 11 11
a. Determine if theclientisexperiencing any anxiety. 11 11 1 11 1 11 11
b. Auscultatethe client’s bilateral lungsoundsandoxygensaturation. 1 11 11 11 11 11 1 1
c. Notifythe healthcare provider aboutthe client’sdistress.
1 11 11 11 1 11 11
d. Assessthe deliverymechanismofthe oxygen tank, tubing, andcannula.
1 11 11 1 1 11 11 11 11 11
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an
11 11 11 11 11 11 11 11 11 11 11 11
immediate investigation by the nurse?
11 11 11 11 11
a. “When I get out of bed quickly, I feel a little dizzy.” 11 11 11 11 11 11 11 11 11 11 11
b. “Thedressingovermy incision feelslike it is too tight.”
1 11 1 11 11 11 11 11 11 11
c. “I’mmostcomfortable when the headofthe bed is raised.”
1 11 11 11 11 1 11 11 11 11
d. “ThisIV infusionmakesmeurinate moreoften than usual.”
1 11 1 1 1 11 1 11 11
