HESI EXIT 6 ICHS | UPDATED Questions with 100% Verified
Answers
Q1: 2. When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that
a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over
the unit intercom after breakfast and after lunch. The nurse is using what communication technique in
responding to the client? a) Doubt b) Observation c) Confrontation d) Reflection
A: d) Reflection c) Confrontation
Q2: 3. The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate
intervention? a) Lip smacking and frequent eye blinking b) Shuffling gait and stooped posture c) Rocks back
and forth in the chair d) Muscle spasms of the back and neck
A: d) Muscle spasms of the back and neck
Q3: 4. A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and
swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day.
To assist the client with self- management of her pain, which information should the nurse obtain? a)
Presence of bruising, weakness, or fatigue b) Therapeutic exercise included in daily routine. c) Average
amount of protein eaten daily d) Existence of gastrointestinal discomfort
A: b) Therapeutic exercise included in daily routine. d) Existence of gastrointestinal discomfort
Q4: 5. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one
RN who was floated from a medical unit. The client with which condition is the best to assign to the float
nurse? a) Diabetic ketoacidosis and titrated IV insulin infusion b) Emphysema extubated 3 hours ago
receiving heated mist c) Subdural hematoma with an intracranial monitoring device d) Acute coronary
syndrome treated with vasopressors
A: a) Diabetic ketoacidosis and titrated IV insulin infusion b) Emphysema extubated 3 hours ago receiving heated mist
Q5: 9. A male client with renal cell carcinoma is returned to the unit following a radical nephrectomy. The
nurse notes that his vital signs and urine output are within normal range, his bandage is dry, and the drain
from the incision site is producing a small amount of serasanguinous drainage. Which intervention should
the nurse implement? a) Place a pressure bandage at the drainage site b) Document assessment findings in
the electronic medical record c) Monitor urinary catheter output for a decrease below 30 ml/hr d) Notify
surgeon of color and amount of wound drainage.
A: Notify surgeon of color and amount of wound drainage b) Document assessment findings in the electronic medical
record
, Q6: 13. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression
devices, which assessment is most important for the nurse to complete? a) Evaluate the client's ability to
use an incentive spirometer b) Monitor the amount of drainage from the client's incision c) Observe both
lower extremities for redness and swelling d) Palpate all peripheral pulse points for volume and strength
A: Monitor the amount of drainage from the client's incision c) Observe both lower extremities for redness and swelling
Q7: 17. Sublingual nitroglycerin is administered to a male client with instable angina who complains of
crushing chest pain. Five minutes later the client becomes nauseated and his blood pressure drops to 60/40.
Which intervention should the nurse implement? a) Give a PRN antiemetic medication b) Infuse a rapid IV
normal saline bolus c) Begin external chest compressions d) Administer second dose of nitroglycerin
A: infuse a rapid IV normal saline bolus
Q8: 18. An adult female client with chronic kidney disease (CKD) is becoming increasingly restless and is
hyperventilating. Urine output is 25 ml/hr and urine pH is 4.5. On admission, her arterial blood gases (ABGs)
are: pH 7.20, PaCO2 37 mEq/L, and HCO3 14 mEq/L. Which action should the nurse implement? a)
Administer IV solution with sodium bicarbonate b) Flush AV fistula with 0.9 Sodium chloride c) Give laxatives
or an enema as client requests d) Maintain the client NPO (nothing by mouth)
A: Administer IV solution with sodium bicarbonate
Q9: 20. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for
the nurse report to the health care provider? a) Decreased white blood cell count b) Pruritus and muscle
aches c) Elevated liver function tests d) Vomiting and diarrhea
A: Elevated liver function tests
Q10: 23. The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red
blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's
cardiopulmonary stability during the blood transfusion? a) Increase the oxygen flow via nasal cannula if
dyspnea is present. b) Place in a Trendelenburg position to increase cerebral blood flow c) Monitor capillary
glucose measurements hourly during transfusion. d) Encourage increased intake of oral fluid to improve
skin turgor.
A: Increase the oxygen flow via nasal cannula if dyspnea is present.
Q11: 24. A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic.
Which assessment finding should prompt the nurse to administer a PRN dose of naloxone (Narcan)? a)
Complaints of increasing flank pain b) Statements about visual hallucinations c) Respiratory rate of 12
breaths/minute d) Unresponsive to verbal or tactile stimuli
A: Unresponsive to verbal or tactile stimuli
Answers
Q1: 2. When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that
a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over
the unit intercom after breakfast and after lunch. The nurse is using what communication technique in
responding to the client? a) Doubt b) Observation c) Confrontation d) Reflection
A: d) Reflection c) Confrontation
Q2: 3. The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate
intervention? a) Lip smacking and frequent eye blinking b) Shuffling gait and stooped posture c) Rocks back
and forth in the chair d) Muscle spasms of the back and neck
A: d) Muscle spasms of the back and neck
Q3: 4. A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and
swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day.
To assist the client with self- management of her pain, which information should the nurse obtain? a)
Presence of bruising, weakness, or fatigue b) Therapeutic exercise included in daily routine. c) Average
amount of protein eaten daily d) Existence of gastrointestinal discomfort
A: b) Therapeutic exercise included in daily routine. d) Existence of gastrointestinal discomfort
Q4: 5. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one
RN who was floated from a medical unit. The client with which condition is the best to assign to the float
nurse? a) Diabetic ketoacidosis and titrated IV insulin infusion b) Emphysema extubated 3 hours ago
receiving heated mist c) Subdural hematoma with an intracranial monitoring device d) Acute coronary
syndrome treated with vasopressors
A: a) Diabetic ketoacidosis and titrated IV insulin infusion b) Emphysema extubated 3 hours ago receiving heated mist
Q5: 9. A male client with renal cell carcinoma is returned to the unit following a radical nephrectomy. The
nurse notes that his vital signs and urine output are within normal range, his bandage is dry, and the drain
from the incision site is producing a small amount of serasanguinous drainage. Which intervention should
the nurse implement? a) Place a pressure bandage at the drainage site b) Document assessment findings in
the electronic medical record c) Monitor urinary catheter output for a decrease below 30 ml/hr d) Notify
surgeon of color and amount of wound drainage.
A: Notify surgeon of color and amount of wound drainage b) Document assessment findings in the electronic medical
record
, Q6: 13. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression
devices, which assessment is most important for the nurse to complete? a) Evaluate the client's ability to
use an incentive spirometer b) Monitor the amount of drainage from the client's incision c) Observe both
lower extremities for redness and swelling d) Palpate all peripheral pulse points for volume and strength
A: Monitor the amount of drainage from the client's incision c) Observe both lower extremities for redness and swelling
Q7: 17. Sublingual nitroglycerin is administered to a male client with instable angina who complains of
crushing chest pain. Five minutes later the client becomes nauseated and his blood pressure drops to 60/40.
Which intervention should the nurse implement? a) Give a PRN antiemetic medication b) Infuse a rapid IV
normal saline bolus c) Begin external chest compressions d) Administer second dose of nitroglycerin
A: infuse a rapid IV normal saline bolus
Q8: 18. An adult female client with chronic kidney disease (CKD) is becoming increasingly restless and is
hyperventilating. Urine output is 25 ml/hr and urine pH is 4.5. On admission, her arterial blood gases (ABGs)
are: pH 7.20, PaCO2 37 mEq/L, and HCO3 14 mEq/L. Which action should the nurse implement? a)
Administer IV solution with sodium bicarbonate b) Flush AV fistula with 0.9 Sodium chloride c) Give laxatives
or an enema as client requests d) Maintain the client NPO (nothing by mouth)
A: Administer IV solution with sodium bicarbonate
Q9: 20. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for
the nurse report to the health care provider? a) Decreased white blood cell count b) Pruritus and muscle
aches c) Elevated liver function tests d) Vomiting and diarrhea
A: Elevated liver function tests
Q10: 23. The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red
blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's
cardiopulmonary stability during the blood transfusion? a) Increase the oxygen flow via nasal cannula if
dyspnea is present. b) Place in a Trendelenburg position to increase cerebral blood flow c) Monitor capillary
glucose measurements hourly during transfusion. d) Encourage increased intake of oral fluid to improve
skin turgor.
A: Increase the oxygen flow via nasal cannula if dyspnea is present.
Q11: 24. A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic.
Which assessment finding should prompt the nurse to administer a PRN dose of naloxone (Narcan)? a)
Complaints of increasing flank pain b) Statements about visual hallucinations c) Respiratory rate of 12
breaths/minute d) Unresponsive to verbal or tactile stimuli
A: Unresponsive to verbal or tactile stimuli
