RN HESI EXIT EXAM (V1) Version 1 | 160 Questions With Answers |Latest Update Graded A+ (2023/2024)

The nurse is caring for a client with bipolar disorder who has Lithium (Lithotabs) prescribed. The nurse should suggest that the client have which of the following snacks? (a) A fresh fruit cup (b) Coffee and oatmeal cookies (c) Tuna fi sh salad on saltine crackers (d) Raw vegetables 44. The nurse has provided discharge instructions for a client who has been prescribed Digoxin (Lanoxin). It would require follow up by the nurse if the client says (a) ―I will consult my primary health care provider before taking medications that contain aspirin.‖ (b) ―I will not take any antacids within two hours of taking the digoxin.‖ (c) ―I will avoid fruits such as avocados, grapefruit and cantaloupe.‖ 11 (d) ―I will remember that any visual disturbance can be a sign of digitalis toxicity.‖ 45. The nurse is caring for a client who has bumetanide (Bumex) prescribed. The nurse should suggest that the client include which of the following foods in the diet? (a) Apricots (b) Organ meats (c) Sardines (d) Apples 46. The nurse is providing teaching for a client with ulcerative colitis. Select all of the following that the nurse should include in the teaching (a) steatorrhea commonly occurs or excessive secretion of fecal lipids is common (b) ulcerative colitis occurs most frequently in Jewish males 30-50 years of age (c) a diet high in residue and low in complex carbohydrates is helpful in controlling symptoms (d) Corticosteroids may be prescribed during an exacerbation (e) metronidazole (Flagyl) and ciprofl oxacin (Cipro) are antibiotics commonly used during acute exacerbations (f) eating small frequent meals and lying down after eating promotes absorption of nutrients 47. The nurse is precepting a newly-hired nurse who is caring for a client receiving a prescribed continuous nasogastric feeding. The nurse should intervene immediately if the newly-hired nurse (a) instills 30cc of normal saline into the feeding tube while auscultating over the stomach for bowel sounds (b) checks the pH of the 60ml gastric aspirate removed from the feeding tube (c) maintains the client with the head of the bed elevated at 45 degrees (d) hangs four hours worth of prescribed feeding formula in an open delivery system 48. The nurse is observing a staff member caring for clients. It would require immediate intervention if the nurse observes the staff member (a) placing a client who had an above-the-knee amputation (AKA) 24 hours ago in a prone position 12 (b) keeping the head of the bed elevated for the client who had an supratentorial craniotomy 12 hours ago (c) giving orange juice to a client who has a clear liquid diet prescribed (d) removing all liquids from the tray before giving the tray to a client who has dumping syndrome 49. The primary health care provider has prescribed ampicillin (Omnipen) 0.5 GM PO Q6H to a 15 month old toddler who weighs 22 pounds. The drug available is ampicillin suspension 250 mg/5 ml. The recommended dosage is 50 mg/kg/ day every 6 to 8 hours. The nurse should (a) call the primary health care provider to report that the prescription exceeds the recommended dosage (b) determine if the toddler has previously had a penicillin or a cephalosporin prescribed (c) give the toddler the ampicillin mixed with applesauce (d) wait until the result of the throat culture obtained one hour ago is reported 50. The nurse is instructing a class for parents of children diagnosed with sickle cell anemia. The nurse should instruct the parents to have the children avoid (a) exposure to hot water (b) other children with infections (c) medications containing aspirin (d) non - contact sports 51. The nurse is assessing a 5-month-old infant. The nurse should expect the infant to (a) roll from abdomen to back (b) sit without support (c) say ‗mama‘ and ‗dada‘ (d) prefer use of one hand over the other 52. The home health care nurse is assigned to see four clients who all live within three miles of each other. The nurse should fi rst see the client who has (a) gastroesophageal refl ux disease (GERD) and is reporting a burning abdominal pain that is relieved by walking (b) cancer of the esophagus who has given away a favorite shirt since the last visit 13 (c) regional enteritis (Crohn‘s disease) who has an elevated temperature and is vomiting (d) a gastrostomy tube who will begin self-feeding for the fi rst time 53. A student nurse is administering magnesium hydroxide/aluminum hydrate (Maalox) prescribed as an antacid to a client. The nursing instructor should intervene if the student plans to administer the antacid (a) two hours after the client has eaten a meal (b) at the same time as a prescribed iron preparation (c) after briskly shaking the bottle of Maalox (d) when assessing the client for the presence of gastric pain 54. The nurse has attended a staff development conference on vitamins and minerals. Which of the following statements if made by the nurse would require follow-up? (a) ―Vitamin B12 (cobalamin) supplement may be needed if a client has a gastrectomy.‖ (b) ―Vitamin D (calciferol) is necessary for proper utilization of calcium and phosphorous.‖ (c) ―Vitamin A can be found in squash, pumpkin, and carrots.‖ (d) ―Vitamin B6 (pyridoxine) supplements are given to help prevent macular degeneration.‖ 55. A nurse is caring for a two-month-old infant being evaluated for congenital hypothyroidism. The nurse should recognize which of the following fi ndings as being consistent with congenital hypothyroidism? (a) The infant sleeps for 6 hours at a time (b) The infant has a high-pitched cry (c) The infant has been having frequent loose stools (d) The infant has 3 + refl exes 56. The nurse in the emergency department is assessing a toddler who has swallowed some bleach. The toddler is crying. It would be a priority for the nurse to follow up if the parent says (a) ―I brought the container of bleach with me.‖ (b) ―I could not get my toddler to vomit.‖ (c) ―I gave my toddler a tablespoonful of ipecac syrup.‖ 14 (d) ―I attempted to perform CPR to prevent my toddler from becoming unresponsive.‖ 57. The nurse is caring for a client who is ventilator dependent. The nurse is aware that the high pressure alarm can be sounded for various reasons. Select all reasons that could apply. (a) increased bronchial secretions (b) the presence of an air leak (c) the presence of a kink in the tubing (d) the client stops breathing spontaneously (e) acute bronchospasm (f) the client is biting the tube (g) the ventilator tubing is disconnected 58. The nurse is caring for a client who has a new colostomy. The colostomy stoma is red, moist and slightly raised. The nurse should (a) determine if the client is allergic to the skin barrier (b) apply petroleum jelly gauze around the stoma (c) document the condition of the stoma (d) assess the client‘s temperature 59. The nurse has attended a staff development conference on medical treatments for various neurological disorders. Which of the following statements if made by the nurse would require follow-up? (a) ―Clients with Guillain-Barre´ syndrome (GBS) often have plasmapheresis prescribed.‖ (b) ―Myasthemia Gravis can be treated with short-acting anticholinesterase drugs.‖ (c) ―Parkinson‘s disease may have catechol O-methyltransferase (COMT) inhibitors prescribed along with levodopoa-carbidopa (Sinemet).‖ (d) ―Clients with Multiple Sclerosis often receive Intravenous immunoglobulin G (IV IgG).‖ 60. The nurse has attended a staff development conference on Meniere‘s Disease. Which of the following statements, if made by the nurse would require follow-up? (a) ―Meniere‘s Disease symptoms result from excess endolymphatic fl uid in the inner ear.‖ (b) ―Clients with Meniere‘s Disease are encouraged to have a low salt diet.‖ 15 (c) ―Assistive listening devices are required for clients with Meniere‘s Disease.‖ (d) ―Stress is suspected to have a role in Meniere‘s Disease.‖ 61. The nurse is admitting a client to the emergency department who is reporting progressive visual impairment and loss of peripheral vision. The nurse should recognize that these symptoms are consistent with the medical diagnosis of (a) macular degeneration (b) closed angle glaucoma (c) senile cataract (d) retinal detachment 62. The nurse is caring for a client who has left ventricular failure. Which of the following should the nurse recognize as being consistent with this diagnosis? (a) 3+ pedal edema (b) jugular vein distention (c) oxygen saturation of 96% (d) wheezing during expiration 63. The nurse has attended a staff development conference on preparing clients for neurological diagnostic tests. Which of the following statements, if made by the nurse would require follow-up? (a) ―The electromyogram (EMG) is performed by introducing small needle electrodes into muscles.‖ (b) ―After having a Positron Emission Tomography (PET) of the head the client can resume normal activities.‖ (c) ―The electroencephalogram (EEG) will require the client to be NPO for 12 hours before the test.‖ (d) ―After the lumbar puncture (LP) the client will need to lie fl at for about 3 hours.‖ 64. The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client (a) who had a cervical radium implant inserted sixteen hours ago is placed on bed rest (b) who had transsphenoidal hypophysectomy twelve hours ago is drinking fl uids through a straw (c) who has received prescribed Lithium for the past three days is observed eating a pickle brought in by a family member 16 (d) who had retinal detachment repaired using a gas bubble four hours ago is lying on the operative side postoperatively 65. The nurse is caring for a client who has oxalate kidney stones. The nurse should teach the client to avoid (a) Spinach and rhubarb (b) Mushrooms and rice (c) Shell fi sh and aged cheese (d) Organ meats and wine 66. A client with end stage renal disease (ESRD) is scheduled for hemodialysis in one hour. The nurse should notify the primary health care provider that the client has a (a) BUN of 60 mg/dl (b) Creatinine 3.5 mg/dl (c) Sodium 145 mEq/L (d) Potassium 6.8 mEq/L 67. The nurse is caring for a 49 year old female client who reports having frequent vaginal yeast infections. The client is 35% over her ideal body weight. The client has had several diagnostic blood tests prescribed. It would be a priority for the nurse to review the results for an elevated (a) fasting blood glucose (b) white blood count (c) hemoglobin (d) blood urea nitrogen 68. The nurse at a health clinic is screening male clients for testicular cancer. It would be a priority for the nurse to teach testicular self examination to (a) a 17-year-old college football player (b) a 39-year-old who smokes a pack of cigarettes day (c) a 55-year-old with benign prostatic hypertrophy (d) a 69-year-old with a family history of testicular cancer 69. The nurse is caring for a 72-year-old client who was recently diagnosed with metastatic breast cancer. The client is expressing feelings of depression and is asking 17 the nurse, ―Why me?‖ According to Erikson, which developmental stage is the client experiencing? (a) Industry vs. inferiority (b) Ego integrity vs. despair (c) Generativity vs. stagnation (d) Intimacy vs. isolation 70. The nurse is caring for several clients who have been prescribed diuretics. The nurse should teach about increasing the consumption of citrus fruits and bananas to the client who has been prescribed (a) amiloride (Midamor ) (b) spironolactone (Aldactone) (c) torsemide (Demadex) (d) triamterene (Dyrenium ) 71. The nurse in a health clinic is reviewing prescribed medications with several clients. It would be a priority for the nurse to follow up with the client who states (a) “I am taking losartan (Cozaar) to lower my blood pressure.‖ (b) ―I crush my verapamil (Calan SR) to make it easier to swallow.‖ (c) ―I try to avoid sudden position changes since I am taking hydralazine (Apresoline).‖ (d) ―I will not use any salt substitutes since I am taking captopril (Capoten).‖ 72. The nurse is developing a plan of care for a client diagnosed with fi bromyalgia. Which nursing diagnosis should the nurse include? (a) Sleep pattern disturbance (b) Risk for infection (c) Fluid volume defi cit (d) Urge urinary incontinence 73. The nurse has attended a staff development conference on sexually transmitted diseases. Which of the following statements, if made by the nurse would require follow-up? (a) ―During the primary stage of syphilis a lesion occurs at the site of infection called a chancre.‖ (b) ―A client with HIV who has a reading of 5 or more on the mantoux test is considered to have a positive fi nding for pulmonary tuberculosis.‖ 18 (c) ―Gonorrhea is often asymptomatic in women but causes urinary frequency and dysuria in males.‖ (d) ―Chlamydial infections are strongly linked with cervical cancer in women.‖ 74. The infection control nurse is making rounds on a Medical Surgical unit. The infection control nurse should immediately intervene if a nurse is observed (a) wearing a disposable surgical face mask when entering the room of a client with active pulmonary tuberculosis (b) keeping the door to the room closed of a client with disseminate varicella zoster (c) leaving a dedicated stethoscope in the room of a client with respiratory syncytial virus (d) wearing a gown, gloves, and mask while taking the blood pressure of a client with Ebola Virus 75. The nurse in a community health setting is assessing the following clients. It would be a priority for the nurse to utilize a multidisciplinary approach for the client who is* (a) 12 years old, with chicken pox and cannot attend school (b) 21 years old, pregnant, unemployed and has active pulmonary tuberculosis (c) 32 years old, a grade school teacher and is recovering from a sickle cell crisis (d) 74 years old, with mild Alzheimer‘s disease and is in an assisted living residence 76. The nurse working in the labor and delivery room has become aware of the following client situations. The nurse should fi rst assess the client who is (a) in the fi rst phase of labor and the fetal heart rate ranges from 128 to 140 between contractions (b) in the fi rst phase of labor and the fetal heart rate is consistently beating at 132 beats per minute (c) in the third phase of labor and the fetal heart rate has decelerated to its lowest point at the acme of the contraction (d) in the third phase of labor and the contractions are lasting 60-70 seconds 77. The nurse is caring for postpartum clients who had vaginal deliveries within the last eight hours. The nurse should fi rst assess the client who (a) has a pulse rate of 66 beats per minute (b) has saturated one perineal pad in two hours (c) reports swelling in her right calf (d) asks if her baby can sleep in the nursery tonight 19 78. The nurse has become aware of the following client situations. It would be a priority for the nurse to follow-up if a client who (a) had a total knee replacement 24 hours ago is using continuous passive motion (CPM) exerciser while in a supine position (b) is scheduled for a myelogram in 4 hours and states ―I can not drink any liquids until after the procedure is fi nished.‖ (c) had a total knee replacement 24 hours ago and is sitting in a fowlers position to eat a meal (d) had a pin inserted 4 hours ago for a fractured femur has a small amount of bright red bleeding at the pin site 79. The nurse is teaching a client about crutch walking. Which of the following statements if made by the client indicates a need for further teaching? (a) ―My elbows should be fl exed 20 - 30 degrees, while walking.‖ (b) ―When I climb stairs I advance my affected leg fi rst, with my crutches.‖ (c) ―I do not apply pressure under my arm when I use my crutches.‖ (d) ―W hen I am going to sit in a chair I put both crutches in the hand on my unaffected side.‖ 80. The nurse on an orthopedic unit has become aware of the following client situations. It would be a priority for the nurse to follow-up if a client who (a) had a total hip replacement 8 hours ago has had 100 ml of bloody drainage in the closed wound suction device (b) has an external fi xation device after a repair of a fractured femur is requesting pain medication (c) had an open reduction and internal fi xation (ORIF) of a fractured femur 12 hours ago has developed a small rash on the chest and neck (d) had a total hip replacement three hours ago has a temperature of 37.8° C (100.2° F) 81. The nurse is caring for a client with a soft tissue injury. The client reports using a herbal remedy for 3 weeks prior to seeking health care but can not remember what was taken. The nurse should recognize that which of the following herbal remedies can be utilized effectively for soft tissue injuries? (a) Saint John‘s Wort (b) Kava Kava 20 (c) Dong–Quai (d) Aloe Vera 82. A client with left-sided weakness following a cerebral vascular accident (CVA) is learning to ambulate with a cane. The nurse should teach the client to (a) hold the cane on the left side and move the cane with the right leg (b) hold the cane on the right side and move the cane with the left leg (c) hold the cane on the left side and move the cane with the left leg (d) hold the cane on the right side and move the cane with the right leg 83. The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client (a) scheduled for an EEG is washing the hair (b) is being transported to have a magnetic resonance image (MRI) test and is attached to a pulse oximeter (c) is being taught to hold the breath at intervals during a computerized tomography (CT Scan) (d) on protective precautions is eating soup brought in by a visitor 84. The nurse is reviewing laboratory data of the following clients. It would be a priority for the nurse to follow-up with the primary health care provider if a client with (a) coronary artery disease has a low density lipoprotein (LDL) level of 129mg/dl (b) primary hypertension has a sodium level of 144mEq/L (c) rhinosinusitis has a white blood count (WBC) of 11,500/ul (d) diabetes mellitus type 1 has a glycosylated hemoglobin (HbA1c) level of 12% 85. The nurse working on a maternity unit has become aware of the following client situations. It would be a priority for the nurse to intervene if a client states (a) ―I will not take my terbutaline (Brethine) if my pulse is greater than 110 beats per minute.‖ (b) ―It is normal for my 10 hour old baby to have blue feet and hands.‖ (c) ―I cannot breast feed because my nipples are cracked and sore.‖ (d) ―I have changed my perineal pad every two hours since I delivered my baby 12 hours ago.‖ 21 86. The nurse observes an adult collapse on the street. Indicate the correct sequence for the nurse to follow. (a) phone emergency medical system at 911 -2 (b) verify unresponsiveness -1 (c) check for breathing -4 (d) establish an airway using a head-tilt/chin-lift -3 Answer 87 A nurse is admitting a client with suspected pulmonary tuberculosis (TB). Which of the following actions should the nurse take? (a) wear a gown when taking the client‘s health history (b) place the client on droplet precautions (c) keep the door to the client‘s room closed (d) use disposable gloves when taking the client‘s blood pressure 88. The charge nurse of a medical-surgical unit notices a nurse walking with an unsteady gait, slurred speech and a faint smell of alcohol on the breath immediately following a lunch break. The charge nurse‘s priority action would be to* (a) notify the nursing supervisor (b) asking the nurse about recent alcohol consumption (c) complete an incident rep