FINAL HESI EXIT EXAMS WITH CORRECT
SOLUTIONS/ACTUAL EXAMS
1. While performing a newborn assessment after a vaginal birth a student
nurse observes a swelling on one side of the top of the head that does
not cross the suture line. The student nurse has identified what clinical
manifestation? - ANSWER-A Cephalohematoma
2. An infant is born with a life-threatening congenital heart defect and is
admitted to the neonatal intensive care unit. What is the priority
nursing intervention at this time? - ANSWER-Assisting the parents with
the grieving process
3. A preterm neonate admitted to the neonatal intensive care nursery
exhibits muscle twitching; seizures; cyanosis; abnormal respirations;
and a short, shrill cry. What complication does the nurse suspect? -
ANSWER-Intracranial hemorrhage
4. A mother whose newborn infant son has a cleft lip and palate asks how
to feed her baby because he has difficulty suckling. What information
should the nurse provide concerning safe feeding technique for this
infant? - ANSWER-"Give him brief rest periods and frequent burpings
during feedings so he can get rid of swallowed air."
5. In specific situations gloves are used to handle newborns whether or
not they are HIV positive. When is it unnecessary for the nurse to wear
gloves while caring for a newborn? - ANSWER-Offering a feeding
6. A nurse is assessing a newborn. What finding indicates the need for
follow-up care? - ANSWER-30-degree abduction of the infant's hips
,7. A nurse who is caring for a 32-week appropriate-for-gestational-age
(AGA) neonate develops a plan of potential interventions for the
neonate. What is the priority intervention? - ANSWER-Maintaining
respirations
8. A nurse is caring for a client who developed aseptic necrosis after a
fracture of the head of the femur. The nurse understands that aseptic
necrosis is associated with which factor? - ANSWER-Loss of blood
supply to the head of the femur
9. An adult client is brought to the emergency department after an
accident. The client has limitations in mental functioning related to
Down syndrome. The nurse can best assess the client's pain level by -
ANSWER-Using Wong's "Pain Faces"
10. A 12-year-old child is admitted to the hospital for observation
after sustaining a head injury. Twelve hours after the injury the child
has none of the signs or symptoms of a head injury. What is the nurse's
priority intervention at this time? - ANSWER-Assessing the level of
consciousness every hour
11. A nurse working at a summer camp is informed of an outbreak of
scabies. What is the classic symptom of scabies for which the nurse
needs to assess the children? - ANSWER-Pruritic threadlike lesions in
skin folds
12. A nurse is in the process of discharging a 9-year-old boy with
recently diagnosed type 1 diabetes. What parental statement indicates
an issue regarding family dynamics? - ANSWER-"We know that our
child is special, so we'll go easy on the discipline."
13. D5W/0.45 NS is infusing intravenously when a 7-year-old child is
returned to the pediatric unit from surgery. The postoperative
prescriptions do not indicate the desired rate of infusion. What is the
, most appropriate action for the nurse to take? - ANSWER-Reduce the
flow rate to keep the vein open and obtain a prescription.
14. A child is admitted to the pediatric intensive care unit with acute
bacterial meningitis. What is the nurse's priority intervention? -
ANSWER-Checking the child's level of consciousness hourly
15. A nurse is caring for a 9-year-old child in the postanesthesia care
unit after craniotomy for the removal of an astrocytoma. Suddenly the
child's right pupil dilates. The priority nursing intervention is: -
ANSWER-Notifying the health care provider
16. A preadolescent brings home a note from the school nurse
informing the parents that the child should be evaluated for scoliosis.
The mother calls the school nurse to ask for a description of scoliosis.
Before responding, the nurse recalls that in scoliosis: - ANSWER-There
is a rotary deformity of the lateral curvature of the spine
17. An 8-year-old child is admitted to the emergency department
with signs and symptoms of Reye syndrome. What information from
the child's history is most important for the nurse to obtain in light of
the child's tentative diagnosis? - ANSWER-Recent viral infection
18. A female client who has recurrent urinary tract infections (UTIs)
is inquiring about the prevention of future UTIs. What information
should the nurse include when teaching the client? Select all that
apply.
19. Drink 8 to 10 glasses of water each day - ANSWER-Urinate
immediately after sexual intercourse
20. A client is to have a parotidectomy to remove a cancerous lesion.
For which postoperative complication that may be permanent should
the nurse monitor? - ANSWER-Facial nerve dysfunction
, 21. A client with Guillain-Barré syndrome has been hospitalized for
three days. Which assessment finding indicates a need for more
frequent monitoring? - ANSWER-Ascending weakness
22. A client comes into the emergency room (ER) after hitting his
head while playing basketball. He is alert and oriented. Which of the
following is a priority nursing intervention? - ANSWER-Immobilize the
client's head and neck
23. A nurse performs full range of motion on a client's extremities.
When putting an ankle through range of motion, the nurse must
perform - ANSWER-Dorsiflexion, plantar flexion, eversion, and inversion
24. A client is admitted to the hospital for surgery to remove a
benign tumor of the neck. What is the best nursing intervention to
assess for wound hemorrhage after the client's surgery? - ANSWER-
Observe the dressing at the back of the neck for the presence of blood.
25. A client is scheduled for a closed magnetic resonance imaging
test (MRI). The client states, "I'm a little scared of small places." What
is the nurse's most appropriate response? - ANSWER-"Mild sedation is
available if you are anxious about lying in a confined area."
26. A client has a total hip arthroplasty. What should the nurse do
when caring for this client after surgery? - ANSWER-Use a pillow to
keep the legs abducted.
27. What should the nurse do to promote early and efficient
ambulation after a client has a mid-thigh amputation? - ANSWER-Turn
the client to the prone position routinely.
SOLUTIONS/ACTUAL EXAMS
1. While performing a newborn assessment after a vaginal birth a student
nurse observes a swelling on one side of the top of the head that does
not cross the suture line. The student nurse has identified what clinical
manifestation? - ANSWER-A Cephalohematoma
2. An infant is born with a life-threatening congenital heart defect and is
admitted to the neonatal intensive care unit. What is the priority
nursing intervention at this time? - ANSWER-Assisting the parents with
the grieving process
3. A preterm neonate admitted to the neonatal intensive care nursery
exhibits muscle twitching; seizures; cyanosis; abnormal respirations;
and a short, shrill cry. What complication does the nurse suspect? -
ANSWER-Intracranial hemorrhage
4. A mother whose newborn infant son has a cleft lip and palate asks how
to feed her baby because he has difficulty suckling. What information
should the nurse provide concerning safe feeding technique for this
infant? - ANSWER-"Give him brief rest periods and frequent burpings
during feedings so he can get rid of swallowed air."
5. In specific situations gloves are used to handle newborns whether or
not they are HIV positive. When is it unnecessary for the nurse to wear
gloves while caring for a newborn? - ANSWER-Offering a feeding
6. A nurse is assessing a newborn. What finding indicates the need for
follow-up care? - ANSWER-30-degree abduction of the infant's hips
,7. A nurse who is caring for a 32-week appropriate-for-gestational-age
(AGA) neonate develops a plan of potential interventions for the
neonate. What is the priority intervention? - ANSWER-Maintaining
respirations
8. A nurse is caring for a client who developed aseptic necrosis after a
fracture of the head of the femur. The nurse understands that aseptic
necrosis is associated with which factor? - ANSWER-Loss of blood
supply to the head of the femur
9. An adult client is brought to the emergency department after an
accident. The client has limitations in mental functioning related to
Down syndrome. The nurse can best assess the client's pain level by -
ANSWER-Using Wong's "Pain Faces"
10. A 12-year-old child is admitted to the hospital for observation
after sustaining a head injury. Twelve hours after the injury the child
has none of the signs or symptoms of a head injury. What is the nurse's
priority intervention at this time? - ANSWER-Assessing the level of
consciousness every hour
11. A nurse working at a summer camp is informed of an outbreak of
scabies. What is the classic symptom of scabies for which the nurse
needs to assess the children? - ANSWER-Pruritic threadlike lesions in
skin folds
12. A nurse is in the process of discharging a 9-year-old boy with
recently diagnosed type 1 diabetes. What parental statement indicates
an issue regarding family dynamics? - ANSWER-"We know that our
child is special, so we'll go easy on the discipline."
13. D5W/0.45 NS is infusing intravenously when a 7-year-old child is
returned to the pediatric unit from surgery. The postoperative
prescriptions do not indicate the desired rate of infusion. What is the
, most appropriate action for the nurse to take? - ANSWER-Reduce the
flow rate to keep the vein open and obtain a prescription.
14. A child is admitted to the pediatric intensive care unit with acute
bacterial meningitis. What is the nurse's priority intervention? -
ANSWER-Checking the child's level of consciousness hourly
15. A nurse is caring for a 9-year-old child in the postanesthesia care
unit after craniotomy for the removal of an astrocytoma. Suddenly the
child's right pupil dilates. The priority nursing intervention is: -
ANSWER-Notifying the health care provider
16. A preadolescent brings home a note from the school nurse
informing the parents that the child should be evaluated for scoliosis.
The mother calls the school nurse to ask for a description of scoliosis.
Before responding, the nurse recalls that in scoliosis: - ANSWER-There
is a rotary deformity of the lateral curvature of the spine
17. An 8-year-old child is admitted to the emergency department
with signs and symptoms of Reye syndrome. What information from
the child's history is most important for the nurse to obtain in light of
the child's tentative diagnosis? - ANSWER-Recent viral infection
18. A female client who has recurrent urinary tract infections (UTIs)
is inquiring about the prevention of future UTIs. What information
should the nurse include when teaching the client? Select all that
apply.
19. Drink 8 to 10 glasses of water each day - ANSWER-Urinate
immediately after sexual intercourse
20. A client is to have a parotidectomy to remove a cancerous lesion.
For which postoperative complication that may be permanent should
the nurse monitor? - ANSWER-Facial nerve dysfunction
, 21. A client with Guillain-Barré syndrome has been hospitalized for
three days. Which assessment finding indicates a need for more
frequent monitoring? - ANSWER-Ascending weakness
22. A client comes into the emergency room (ER) after hitting his
head while playing basketball. He is alert and oriented. Which of the
following is a priority nursing intervention? - ANSWER-Immobilize the
client's head and neck
23. A nurse performs full range of motion on a client's extremities.
When putting an ankle through range of motion, the nurse must
perform - ANSWER-Dorsiflexion, plantar flexion, eversion, and inversion
24. A client is admitted to the hospital for surgery to remove a
benign tumor of the neck. What is the best nursing intervention to
assess for wound hemorrhage after the client's surgery? - ANSWER-
Observe the dressing at the back of the neck for the presence of blood.
25. A client is scheduled for a closed magnetic resonance imaging
test (MRI). The client states, "I'm a little scared of small places." What
is the nurse's most appropriate response? - ANSWER-"Mild sedation is
available if you are anxious about lying in a confined area."
26. A client has a total hip arthroplasty. What should the nurse do
when caring for this client after surgery? - ANSWER-Use a pillow to
keep the legs abducted.
27. What should the nurse do to promote early and efficient
ambulation after a client has a mid-thigh amputation? - ANSWER-Turn
the client to the prone position routinely.
