HESI EXIT 2 ICHS | UPDATED Questions with 100% Verified
Answers
Q1: The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for
disease and symptom management. Which statement by the client indicates understanding?
A: B Get an eye examination with an ophthalmologist annually.
Q2: A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed
narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention
should the nurse implement?
A: B Position bedside table so the client can lean across it.
Q3: A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission
procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is
lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has
always been alert and communicative. Which action should the nurse take?
A: D Explain the postictal state that usually follows seizures.
Q4: When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia
rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse
implement first?
A: D Check for a distended bladder.
Q5: The nurse is caring for a client on the first day postoperative for a descending aortic aneurysm repair.
Which assessment finding should the nurse prioritize reporting to the healthcare provider?
A: B Electrocardiogram ST segment elevation.
Q6: The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food
selection indicate to the nurse that the client understand the prescribed diet?
A: C Roasted turkey, canned vegetables.
Q7: A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease
(COPD) and peripheral vascular disease (PVD) is being discharged from a skilled nursing facility. Which
action is most important for the nurse to implement?
A: C Provide typed instructions for healthy diet selection
, Q8: A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing
action has the highest priority?
A: C Initiate a continuous infusion of IV fluids per prescription.
Q9: A male client reports to the on-call clinic nurse that he took tadalafil 10mg by mouth two hours ago and
his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or
recent chest pain. What action should the nurse take?
A: C Reassure the client that skin flushing is a common side effect of the medication.
Q10: An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the
emergency department (ED) with full thickness burns to all surfaces of both lower extremities. Which
percentage of body surface area should the nurse document in the electronic medical record (EMR)?
A: B 36%.
Q11: What nursing intervention is particularly indicated for the second stage of labor?
A: D Assisting the client to push effectively so that expulsion of the fetus can be achieved.
Q12: A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg
intravenously every 12 hours. The vial is labeled, "10 mg/mL." How many mL should the nurse administer?
(Enter numeric value only.)
A: 4 mL
Q13: An adult client is admitted to the critical care unit with systemic inflammatory response syndrome
(SIRS) as a result of a postbur infection. The client has a long line peripherally inserted IV catheter for fluid
and medication administration and current vital signs include temperature 102.8° F (39.3° C), heart rate 108
beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first?
A: B Culture sputum, urine, burn wound, and all intravenous access sites.
Q14: The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL.".
How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the
nearest tenth.)
A: 0.2 mL
Answers
Q1: The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for
disease and symptom management. Which statement by the client indicates understanding?
A: B Get an eye examination with an ophthalmologist annually.
Q2: A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed
narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention
should the nurse implement?
A: B Position bedside table so the client can lean across it.
Q3: A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission
procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is
lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has
always been alert and communicative. Which action should the nurse take?
A: D Explain the postictal state that usually follows seizures.
Q4: When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia
rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse
implement first?
A: D Check for a distended bladder.
Q5: The nurse is caring for a client on the first day postoperative for a descending aortic aneurysm repair.
Which assessment finding should the nurse prioritize reporting to the healthcare provider?
A: B Electrocardiogram ST segment elevation.
Q6: The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food
selection indicate to the nurse that the client understand the prescribed diet?
A: C Roasted turkey, canned vegetables.
Q7: A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease
(COPD) and peripheral vascular disease (PVD) is being discharged from a skilled nursing facility. Which
action is most important for the nurse to implement?
A: C Provide typed instructions for healthy diet selection
, Q8: A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing
action has the highest priority?
A: C Initiate a continuous infusion of IV fluids per prescription.
Q9: A male client reports to the on-call clinic nurse that he took tadalafil 10mg by mouth two hours ago and
his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or
recent chest pain. What action should the nurse take?
A: C Reassure the client that skin flushing is a common side effect of the medication.
Q10: An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the
emergency department (ED) with full thickness burns to all surfaces of both lower extremities. Which
percentage of body surface area should the nurse document in the electronic medical record (EMR)?
A: B 36%.
Q11: What nursing intervention is particularly indicated for the second stage of labor?
A: D Assisting the client to push effectively so that expulsion of the fetus can be achieved.
Q12: A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg
intravenously every 12 hours. The vial is labeled, "10 mg/mL." How many mL should the nurse administer?
(Enter numeric value only.)
A: 4 mL
Q13: An adult client is admitted to the critical care unit with systemic inflammatory response syndrome
(SIRS) as a result of a postbur infection. The client has a long line peripherally inserted IV catheter for fluid
and medication administration and current vital signs include temperature 102.8° F (39.3° C), heart rate 108
beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first?
A: B Culture sputum, urine, burn wound, and all intravenous access sites.
Q14: The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL.".
How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the
nearest tenth.)
A: 0.2 mL
