HESI EXIT QUESTIONS WITH COMPLETE SOLUTIONS
The nurse performs a prescribed neurological check at the beginning of the
shift on a client who was admitted to the hospital with a subarachnoid brain
attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What
information is most important for the nurse to determine?
• The client's previous GCS score
• When the client's stroke symptoms started
• If the client is oriented to time
• The client's blood pressure and respiration rate
Correct Ans ~ A
Rationale: The normal GCS is 15, and it is most important for the nurse to
determine if it abnormal score a sign of improvement or a deterioration in
the
client's condition
Based on principles of asepsis, the nurse should consider which circumstance
to be sterile?
• One inch- border around the edge of the sterile field set up in the operating
room
• A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
• An open sterile Foley catheter kit set up on a table at the nurse waist level
• Sterile syringe is placed on sterile area as the nurse riches over the sterile
field.
Correct Ans ~ C
Rationale: A sterile package at or above the waist level is considered sterile.
The
edge of sterile field is contaminated which include a 1-inch border (A). A
sterile
objects become contaminated by capillary action when sterile objects
become in
contact with a wet contaminated surface.
An unlicensed assistive personnel (UAP) reports that a client's right hand and
fingers spasms when taking the blood pressure using the same arm. After
confirming the presence of spams what action should the nurse take?
• Ask the UAP to take the blood pressure in the other arm
• Tell the UAP to use a different sphygmomanometer.
• Review the client's serum calcium level
• Administer PRN antianxiety medication.
Correct Ans ~ C
Rationale: Trousseau's sign is indicated by spasms in the distal portion of an
extremity that is being used to measure blood pressure and is caused by
hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.
,A 56-years-old man shares with the nurse that he is having difficulty making
decision about terminating life support for his wife. What is the best initial
action by the nurse?
• Provide an opportunity for him to clarify his values related to the decision
• Encourage him to share memories about his life with his wife and family
• Advise him to seek several opinions before making decision
• Offer to contact the hospital chaplain or social worker to offer support.
Correct Ans ~ A
Rationale: When a client is faced with a decisional conflict, the nurse should
first provide opportunities for the client to clarify values important in the
decision. The rest may also be beneficial once the client as clarified the
values that are important to him in the decision-making process
A client is being discharged home after being treated for heart failure (HF).
What instruction should the nurse include in this client's discharge teaching
plan?
• Weigh every morning
• Eat a high protein diet
• Perform range of motion exercises
• Limit fluid intake to 1,500 ml daily
Correct Ans ~ A
A child with heart failure is receiving the diuretic furosemide (Lasix) and has
serum potassium level 3.0 mEq/L. Which assessment is most important for
the nurse to obtain?
• Cardiac rhythm and heart rate.
• Daily intake of foods rich in potassium.
• Hourly urinary output
• Thirst ad skin turgor.
Correct Ans ~ A
The nurse note a depressed female client has been more withdrawn and non
communicative during the past two weeks. Which intervention is most
important to include in the updated plan of care for this client?
• Encourage the client's family to visit more often
• Schedule a daily conference with the social worker
• Encourage the client to participate in group activities
• Engage the client in a non-threatening conversation.
Correct Ans ~ D
Rationale: Consistent attempts to draw the client into conversations which
focus on non-threatening subjects can be an effective means of eliciting a
response, thereby decreasing isolation behaviors. There is not sufficient data
to support the effectiveness of A as an intervention for this client. Although B
may be indicated, nursing interventions can also be used to treat this client.
C is too threatening to this client.
,A client with rheumatoid arthritis (RA) starts a new prescription of etanercept
(Enbrel) subcutaneously once weekly. The nurse should emphasize the
importance of
reporting problem to the healthcare provider?
• Headache
• Joint stiffness
• Persistent fever
• Increase hunger and thirst
Correct Ans ~ C
Rationale: Enbrel decrease immune and inflammatory responses, increasing
the client's risk of serious infection, so the client should be instructed to
report a persistent fever, or other signs of infection to the healthcare
provider.
The nurse is assessing an older adult with type 2 diabetes mellitus. Which
assessment finding indicates that the client understands long- term control
of diabetes?
• The fating blood sugar was 120 mg/dl this morning.
• Urine ketones have been negative for the past 6 months
• The hemoglobin A1C was 6.5g/100 ml last week
• No diabetic ketoacidosis has occurred in 6 months.
Correct Ans ~ C
Rationale: A hemoglobin A1C level reflects he average blood sugar the client
had over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that
the client understand long-term diabetes control. Normal value in a diabetic
patient is up to 6.5 g/100 ml.
A 13 years-old client with non-union of a comminuted fracture of the tibia is
admitted with osteomyelitis. The healthcare provider collects home aspirate
specimens for culture and sensitivity and applies a cast to the adolescent's
lower leg. What action should the nurse implement next?
• Administer antiemetic agents
• Bivalve the cast for distal compromise
• Provide high- calorie, high-protein diet
• Begin parenteral antibiotic therapy
Correct Ans ~ D
Rationale: The standard of treatment for osteomyelitis is antibiotic therapy
and
immobilization. After bond and blood aspirate specimens are obtained for
culture and sensitivity, the nurse should initiate parenteral antibiotics as
prescribed.
A male client receives a thrombolytic medication following a myocardial
infarction. When the client has a bowel movement, what action should the
nurse implement?
• Send stool sample to the lab for a guaiac test
, • Observe stool for a day-colored appearance.
• Obtain specimen for culture and sensitivity analysis
• Asses for fatty yellow streaks in the client's stool.
Correct Ans ~ A
Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac
(occult blood test) test of the stool should be evaluated to detect bleeding in
the
intestinal tract
In early septic shock states, what is the primary cause of hypotension?
• Peripheral vasoconstriction
• Peripheral vasodilation
• Cardiac failure
• A vagal response
Correct Ans ~ B
Rationale: Toxins released by bacteria in septic shock create massive
peripheral vasodilation and increase microvascular permeability at the site of
the bacterial invasion.
A client diagnosed with calcium kidney stones has a history of gout. A new
prescription for aluminum hydroxide (Amphogel) is scheduled to begin at
0730. Which client medication should the nurse bring to the healthcare
provider's attention?
• Allopurinol (Zyloprim)
• Aspirin, low dose
• Furosemide (lasix)
• Enalapril (vasote)
Correct Ans ~ A
A male client's laboratory results include a platelet count of 105,000/ mm3
Based on
this finding the nurse should include which action in the client's plan of care?
• Cluster care to conserve energy
• Initiate contact isolation
• Encourage him to use an electric razor
• Asses him for adventitious lung sounds
Correct Ans ~ C
Rationale: This client is at risk for bleeding based on his platelet count
(normal
150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for
shaving, should be encouraged to reduce the risk of bleeding.
A client is admitted to the hospital after experiencing a brain attack,
commonly
referred to as a stroke or cerebral vascular accident (CVA). The nurse should
request a referral for speech therapy if the client exhibits which finding?
The nurse performs a prescribed neurological check at the beginning of the
shift on a client who was admitted to the hospital with a subarachnoid brain
attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What
information is most important for the nurse to determine?
• The client's previous GCS score
• When the client's stroke symptoms started
• If the client is oriented to time
• The client's blood pressure and respiration rate
Correct Ans ~ A
Rationale: The normal GCS is 15, and it is most important for the nurse to
determine if it abnormal score a sign of improvement or a deterioration in
the
client's condition
Based on principles of asepsis, the nurse should consider which circumstance
to be sterile?
• One inch- border around the edge of the sterile field set up in the operating
room
• A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
• An open sterile Foley catheter kit set up on a table at the nurse waist level
• Sterile syringe is placed on sterile area as the nurse riches over the sterile
field.
Correct Ans ~ C
Rationale: A sterile package at or above the waist level is considered sterile.
The
edge of sterile field is contaminated which include a 1-inch border (A). A
sterile
objects become contaminated by capillary action when sterile objects
become in
contact with a wet contaminated surface.
An unlicensed assistive personnel (UAP) reports that a client's right hand and
fingers spasms when taking the blood pressure using the same arm. After
confirming the presence of spams what action should the nurse take?
• Ask the UAP to take the blood pressure in the other arm
• Tell the UAP to use a different sphygmomanometer.
• Review the client's serum calcium level
• Administer PRN antianxiety medication.
Correct Ans ~ C
Rationale: Trousseau's sign is indicated by spasms in the distal portion of an
extremity that is being used to measure blood pressure and is caused by
hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.
,A 56-years-old man shares with the nurse that he is having difficulty making
decision about terminating life support for his wife. What is the best initial
action by the nurse?
• Provide an opportunity for him to clarify his values related to the decision
• Encourage him to share memories about his life with his wife and family
• Advise him to seek several opinions before making decision
• Offer to contact the hospital chaplain or social worker to offer support.
Correct Ans ~ A
Rationale: When a client is faced with a decisional conflict, the nurse should
first provide opportunities for the client to clarify values important in the
decision. The rest may also be beneficial once the client as clarified the
values that are important to him in the decision-making process
A client is being discharged home after being treated for heart failure (HF).
What instruction should the nurse include in this client's discharge teaching
plan?
• Weigh every morning
• Eat a high protein diet
• Perform range of motion exercises
• Limit fluid intake to 1,500 ml daily
Correct Ans ~ A
A child with heart failure is receiving the diuretic furosemide (Lasix) and has
serum potassium level 3.0 mEq/L. Which assessment is most important for
the nurse to obtain?
• Cardiac rhythm and heart rate.
• Daily intake of foods rich in potassium.
• Hourly urinary output
• Thirst ad skin turgor.
Correct Ans ~ A
The nurse note a depressed female client has been more withdrawn and non
communicative during the past two weeks. Which intervention is most
important to include in the updated plan of care for this client?
• Encourage the client's family to visit more often
• Schedule a daily conference with the social worker
• Encourage the client to participate in group activities
• Engage the client in a non-threatening conversation.
Correct Ans ~ D
Rationale: Consistent attempts to draw the client into conversations which
focus on non-threatening subjects can be an effective means of eliciting a
response, thereby decreasing isolation behaviors. There is not sufficient data
to support the effectiveness of A as an intervention for this client. Although B
may be indicated, nursing interventions can also be used to treat this client.
C is too threatening to this client.
,A client with rheumatoid arthritis (RA) starts a new prescription of etanercept
(Enbrel) subcutaneously once weekly. The nurse should emphasize the
importance of
reporting problem to the healthcare provider?
• Headache
• Joint stiffness
• Persistent fever
• Increase hunger and thirst
Correct Ans ~ C
Rationale: Enbrel decrease immune and inflammatory responses, increasing
the client's risk of serious infection, so the client should be instructed to
report a persistent fever, or other signs of infection to the healthcare
provider.
The nurse is assessing an older adult with type 2 diabetes mellitus. Which
assessment finding indicates that the client understands long- term control
of diabetes?
• The fating blood sugar was 120 mg/dl this morning.
• Urine ketones have been negative for the past 6 months
• The hemoglobin A1C was 6.5g/100 ml last week
• No diabetic ketoacidosis has occurred in 6 months.
Correct Ans ~ C
Rationale: A hemoglobin A1C level reflects he average blood sugar the client
had over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that
the client understand long-term diabetes control. Normal value in a diabetic
patient is up to 6.5 g/100 ml.
A 13 years-old client with non-union of a comminuted fracture of the tibia is
admitted with osteomyelitis. The healthcare provider collects home aspirate
specimens for culture and sensitivity and applies a cast to the adolescent's
lower leg. What action should the nurse implement next?
• Administer antiemetic agents
• Bivalve the cast for distal compromise
• Provide high- calorie, high-protein diet
• Begin parenteral antibiotic therapy
Correct Ans ~ D
Rationale: The standard of treatment for osteomyelitis is antibiotic therapy
and
immobilization. After bond and blood aspirate specimens are obtained for
culture and sensitivity, the nurse should initiate parenteral antibiotics as
prescribed.
A male client receives a thrombolytic medication following a myocardial
infarction. When the client has a bowel movement, what action should the
nurse implement?
• Send stool sample to the lab for a guaiac test
, • Observe stool for a day-colored appearance.
• Obtain specimen for culture and sensitivity analysis
• Asses for fatty yellow streaks in the client's stool.
Correct Ans ~ A
Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac
(occult blood test) test of the stool should be evaluated to detect bleeding in
the
intestinal tract
In early septic shock states, what is the primary cause of hypotension?
• Peripheral vasoconstriction
• Peripheral vasodilation
• Cardiac failure
• A vagal response
Correct Ans ~ B
Rationale: Toxins released by bacteria in septic shock create massive
peripheral vasodilation and increase microvascular permeability at the site of
the bacterial invasion.
A client diagnosed with calcium kidney stones has a history of gout. A new
prescription for aluminum hydroxide (Amphogel) is scheduled to begin at
0730. Which client medication should the nurse bring to the healthcare
provider's attention?
• Allopurinol (Zyloprim)
• Aspirin, low dose
• Furosemide (lasix)
• Enalapril (vasote)
Correct Ans ~ A
A male client's laboratory results include a platelet count of 105,000/ mm3
Based on
this finding the nurse should include which action in the client's plan of care?
• Cluster care to conserve energy
• Initiate contact isolation
• Encourage him to use an electric razor
• Asses him for adventitious lung sounds
Correct Ans ~ C
Rationale: This client is at risk for bleeding based on his platelet count
(normal
150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for
shaving, should be encouraged to reduce the risk of bleeding.
A client is admitted to the hospital after experiencing a brain attack,
commonly
referred to as a stroke or cerebral vascular accident (CVA). The nurse should
request a referral for speech therapy if the client exhibits which finding?
