EXIT HESI PN COMPREHENSIVE ANSWERS AND
QUESTIONS SET A+
✔✔Until the census on the obstetrics (OB) unit increases, an unlicensed assistive
personnel (UAP) who usually works in labor and delivery and the newborn nursery is
assigned to work on the postoperative unit. Which client would be best for the charge
nurse to assign to this UAP?
A.An adolescent who was readmitted to the hospital because of a postoperative
infection
B.A woman with a new colostomy who requires discharge teaching
C.A woman who had a hip replacement and may be transferred to the home care unit
D.A man who had a cholecystectomy and currently has a nasogastric tube set to
intermittent suction - ✔✔C
The charge nurse will be responsible for providing a report to the home care unit if the
transfer occurs (A). The client is infected and an employee who works on an OB unit
should be assigned to clean cases in case the employee is required to return to the OB
unit (B). This requires the skills of a registered nurse (RN) to do discharge teaching and
provide emotional support (D). This may require skills beyond the level of this UAP.
✔✔A male client is admitted for observation after being hit on the head with a baseball
bat. Six hours after admission, the client attempts to crawl out of bed and asks the
nurse why there are so many bugs in his bed. His vital signs are stable, and the pulse
oximeter reading is 98% on room air. Which intervention should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed. - ✔✔C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental
status (C). It is important to act early and quickly when symptoms of increased ICP
occur. Because his oxygen saturation is normal, the administration of oxygen (A) is not
the top priority. Vital signs should be monitored frequently (B), but the client's confusion
should be reported immediately. (D) is not a useful intervention.
,✔✔The nurse is monitoring a client who is receiving bedside conscious sedation with
midazolam hydrochloride (Versed). In assessing the client, the nurse determines that
the client has slurred speech with diplopia. Based on this finding, what action should the
nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
D.Continue to monitor the client. - ✔✔D
The desired level III in conscious sedation includes slurred speech, glazed eyes, and
marked diplopia. Because this is the desired outcome of the medication regimen, no
action is needed but continuing to monitor the client (D). The airway is open if the client
is able to talk (A). There are no signs of hypoglycemia (B). No reversal is necessary for
the benzodiazepine (Versed) without signs of oversedation, such as respiratory
depression (C).
✔✔The nurse is assessing a client using the Snellen chart and determines that the
client's visual acuity is the same as in a previous examination, which was recorded as
20/100. When the client asks the meaning of this, which information should the nurse
provide?
A.This visual acuity result is five times worse that of a normal finding.
B.This line should be seen clearly when the client wears corrective lenses.
C.A client with normal vision can read at 100 feet what this client reads at 20 feet.
D.This client can see at 100 feet what a client with normal vision can see at 20 feet. -
✔✔C
The interpretation of the client's visual acuity is compared to the Snellen scale of 20/20,
which indicates that the letter size on the Snellen chart is seen clearly and read by a
client with normal vision at 20 feet. A finding of 20/100 means that this client can read at
20 feet what a person with normal vision can read at 100 feet (C). (A, B, and D) are
inaccurate.
✔✔A client with small cell carcinoma of the lung has also developed syndrome of
inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for
this client?
A.Reduced peripheral edema
B.Urinary output of at least 70 mL/hr
C.Decrease in urine osmolarity
D.Serum sodium level of 137 mEq/L - ✔✔D
Syndrome of inappropriate antidiuretic hormone (SIADH) results from an abnormal
production or sustained secretion of antidiuretic hormone, causing fluid retention,
hyponatremia, and central nervous system (CNS) fluid shifts. The client's normalization
of the serum sodium level (normal is 135 to 145 mEq/L) (D) is the most important
outcome because sudden and severe hyponatremia caused by fluid overload can result
, in heart failure. Fluid retention of SIADH contributes to daily weight gain, which can
predispose to peripheral edema (A), but the higher priority outcome is the effect on
serum electrolyte levels. Although (B and C) are findings associated with resolving
SIADH, they do not have the priority of (D).
✔✔Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of
depression is hemodynamically stable but wants to leave the hospital against medical
advice. Which nursing action(s) is(are) most likely to maintain client safety?
(Select all that apply.)
A.Direct the client to sign a liability release form.
B.Restrict the client's ability to leave the unit.
C.Explain the benefits of remaining in the hospital.
D.Instruct the client to take medications as prescribed.
E.Provide the client with names of local support groups.
F.Notify the health care provider of the client's intention. - ✔✔CDF
Correct responses are (C, D, and F). To maintain safety and to provide information, the
nurse should explain the potential benefits of continuing treatment in the hospital (C)
and the need to take prescribed medications (D). This client, who is very likely self-
destructive, should remain on the unit and the health care provider should be notified
(F). Signing a release form (A) before leaving the hospital does not contribute to safety.
The nurse may ask the client not to leave the hospital (B), but pressuring clients is
unethical behavior. (E) may be helpful at a later time in this client's treatment program.
✔✔Which assessment finding indicates that nystatin (Mycostatin) swish and swallow,
prescribed for a client with oral candidiasis, has been effective?
A.The client denies dysphagia.
B.The client is afebrile with warm and dry skin.
C.The oral mucosa is pink and intact.
D.There is no reflux following food intake. - ✔✔C
Mycostatin swish and swallow is prescribed for its local effect on the oral mucosa,
reducing the white curdlike lesions in the mouth and larynx (C). The ability to swallow
(A) does not indicate that the medication has been effective. (B and D) do not reflect
effectiveness of the local medication.
✔✔Because of census overload, the charge nurse of an acute care medical unit must
select a client who can be transferred back to a residential facility. The client with which
symptomology is the most stable?
A.A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus
aureus (MRSA)
B.Pneumonia, with a sputum culture of gram-negative bacteria
C.Urinary tract infection, with positive blood cultures
D.Culture of a diabetic foot ulcer shows gram-positive cocci - ✔✔A
QUESTIONS SET A+
✔✔Until the census on the obstetrics (OB) unit increases, an unlicensed assistive
personnel (UAP) who usually works in labor and delivery and the newborn nursery is
assigned to work on the postoperative unit. Which client would be best for the charge
nurse to assign to this UAP?
A.An adolescent who was readmitted to the hospital because of a postoperative
infection
B.A woman with a new colostomy who requires discharge teaching
C.A woman who had a hip replacement and may be transferred to the home care unit
D.A man who had a cholecystectomy and currently has a nasogastric tube set to
intermittent suction - ✔✔C
The charge nurse will be responsible for providing a report to the home care unit if the
transfer occurs (A). The client is infected and an employee who works on an OB unit
should be assigned to clean cases in case the employee is required to return to the OB
unit (B). This requires the skills of a registered nurse (RN) to do discharge teaching and
provide emotional support (D). This may require skills beyond the level of this UAP.
✔✔A male client is admitted for observation after being hit on the head with a baseball
bat. Six hours after admission, the client attempts to crawl out of bed and asks the
nurse why there are so many bugs in his bed. His vital signs are stable, and the pulse
oximeter reading is 98% on room air. Which intervention should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed. - ✔✔C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental
status (C). It is important to act early and quickly when symptoms of increased ICP
occur. Because his oxygen saturation is normal, the administration of oxygen (A) is not
the top priority. Vital signs should be monitored frequently (B), but the client's confusion
should be reported immediately. (D) is not a useful intervention.
,✔✔The nurse is monitoring a client who is receiving bedside conscious sedation with
midazolam hydrochloride (Versed). In assessing the client, the nurse determines that
the client has slurred speech with diplopia. Based on this finding, what action should the
nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
D.Continue to monitor the client. - ✔✔D
The desired level III in conscious sedation includes slurred speech, glazed eyes, and
marked diplopia. Because this is the desired outcome of the medication regimen, no
action is needed but continuing to monitor the client (D). The airway is open if the client
is able to talk (A). There are no signs of hypoglycemia (B). No reversal is necessary for
the benzodiazepine (Versed) without signs of oversedation, such as respiratory
depression (C).
✔✔The nurse is assessing a client using the Snellen chart and determines that the
client's visual acuity is the same as in a previous examination, which was recorded as
20/100. When the client asks the meaning of this, which information should the nurse
provide?
A.This visual acuity result is five times worse that of a normal finding.
B.This line should be seen clearly when the client wears corrective lenses.
C.A client with normal vision can read at 100 feet what this client reads at 20 feet.
D.This client can see at 100 feet what a client with normal vision can see at 20 feet. -
✔✔C
The interpretation of the client's visual acuity is compared to the Snellen scale of 20/20,
which indicates that the letter size on the Snellen chart is seen clearly and read by a
client with normal vision at 20 feet. A finding of 20/100 means that this client can read at
20 feet what a person with normal vision can read at 100 feet (C). (A, B, and D) are
inaccurate.
✔✔A client with small cell carcinoma of the lung has also developed syndrome of
inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for
this client?
A.Reduced peripheral edema
B.Urinary output of at least 70 mL/hr
C.Decrease in urine osmolarity
D.Serum sodium level of 137 mEq/L - ✔✔D
Syndrome of inappropriate antidiuretic hormone (SIADH) results from an abnormal
production or sustained secretion of antidiuretic hormone, causing fluid retention,
hyponatremia, and central nervous system (CNS) fluid shifts. The client's normalization
of the serum sodium level (normal is 135 to 145 mEq/L) (D) is the most important
outcome because sudden and severe hyponatremia caused by fluid overload can result
, in heart failure. Fluid retention of SIADH contributes to daily weight gain, which can
predispose to peripheral edema (A), but the higher priority outcome is the effect on
serum electrolyte levels. Although (B and C) are findings associated with resolving
SIADH, they do not have the priority of (D).
✔✔Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of
depression is hemodynamically stable but wants to leave the hospital against medical
advice. Which nursing action(s) is(are) most likely to maintain client safety?
(Select all that apply.)
A.Direct the client to sign a liability release form.
B.Restrict the client's ability to leave the unit.
C.Explain the benefits of remaining in the hospital.
D.Instruct the client to take medications as prescribed.
E.Provide the client with names of local support groups.
F.Notify the health care provider of the client's intention. - ✔✔CDF
Correct responses are (C, D, and F). To maintain safety and to provide information, the
nurse should explain the potential benefits of continuing treatment in the hospital (C)
and the need to take prescribed medications (D). This client, who is very likely self-
destructive, should remain on the unit and the health care provider should be notified
(F). Signing a release form (A) before leaving the hospital does not contribute to safety.
The nurse may ask the client not to leave the hospital (B), but pressuring clients is
unethical behavior. (E) may be helpful at a later time in this client's treatment program.
✔✔Which assessment finding indicates that nystatin (Mycostatin) swish and swallow,
prescribed for a client with oral candidiasis, has been effective?
A.The client denies dysphagia.
B.The client is afebrile with warm and dry skin.
C.The oral mucosa is pink and intact.
D.There is no reflux following food intake. - ✔✔C
Mycostatin swish and swallow is prescribed for its local effect on the oral mucosa,
reducing the white curdlike lesions in the mouth and larynx (C). The ability to swallow
(A) does not indicate that the medication has been effective. (B and D) do not reflect
effectiveness of the local medication.
✔✔Because of census overload, the charge nurse of an acute care medical unit must
select a client who can be transferred back to a residential facility. The client with which
symptomology is the most stable?
A.A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus
aureus (MRSA)
B.Pneumonia, with a sputum culture of gram-negative bacteria
C.Urinary tract infection, with positive blood cultures
D.Culture of a diabetic foot ulcer shows gram-positive cocci - ✔✔A
