HESI EXIT V2
1. Patient: Pre-adolescent in skeletal Dunlop traction.
Situation: The nurse is caring for the child in traction.
Question: What is the appropriate nursing intervention?
A) Ensure the child is in correct body alignment.
B) Make sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort.
D) Release the traction for 15-20 minutes every 6 hours as needed.
Answer: A
Feedback: Proper alignment helps in effective healing and prevents complications.
2. Patient: Healthy child at a 2-year check-up.
Situation: The nurse is assessing the child.
Question: Which finding should be reported immediately to the healthcare provider?
A) Significant variance in height and weight percentiles.
B) Growth pattern appears to have slowed.
C) Recumbent and standing height are different.
D) Short-term weight changes are uneven.
Answer: A
Feedback: Variations can indicate growth or developmental issues requiring further evaluation.
3. Patient: 2-year-old child holding breath during temper tantrums.
Situation: Parents report breath-holding during tantrums.
Question: What is the best action by the nurse?
, A) Teach the parents how to perform cardiopulmonary resuscitation.
B) Recommend that the parents give in when he holds his breath to prevent anoxia.
C) Advise parents to ignore breath-holding as the child will resume breathing naturally.
D) Instruct the parents on how to reason with the child about possible harmful effects.
Answer: C
Feedback: Breath-holding typically resolves without intervention and does not cause long-term harm.
4. Patient: Client in the emergency room.
Situation: The client describes chest pain.
Question: Which statement suggests acute angina?
A) "My pain is deep in my chest behind my sternum."
B) "When I sit up the pain gets worse."
C) "As I take a deep breath the pain gets worse."
D) "The pain is right here in my stomach area."
Answer: A
Feedback: This type of pain location is characteristic of angina, needing immediate attention.
5. Patient: Client with possible organic brain disorder.
Situation: The nurse is assessing mental status.
Question: Which question best assesses recent memory function?
A) "Name the year." "What season is this?" (pause for answer after each question)
B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to
subtract 7 from the new number."
C) "I am going to say three words and I want you to repeat them after me: blue, ball, pen."
D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"
Answer: C
,Feedback: This test evaluates the ability to recall recent information, critical in memory assessment.
6. Patient: 6-month-old infant.
Situation: Planning care for the infant.
Question: What must the nurse provide to assist in developing trust?
A) Food.
B) Warmth.
C) Security.
D) Comfort.
Answer: C
Feedback: Consistent and responsive care helps infants develop a sense of security and trust.
7. Situation: Nurse receives an illegible medication order.
Question: Which statement best reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean."
B) "Could you please clarify what you have written so I am sure I am reading it correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful."
D) "Please print in the future so I do not have to spend extra time attempting to read your writing."
Answer: B
Feedback: Clear communication ensures safe medication administration and patient safety.
8. Situation: Teaching parents to reduce home risks.
Question: What is the most important consideration?
A) Age and knowledge level of the parents.
B) Proximity to emergency services.
, C) Number of children in the home.
D) Age of children in the home.
Answer: D
Feedback: Different ages pose different risks; safety measures should be age-appropriate.
9. Patient: 35-year-old client with sickle cell crisis.
Situation: The client requests pain relief.
Question: What should the nurse do?
A) Administer a placebo.
B) Encourage increased fluid intake.
C) Administer the prescribed analgesic.
D) Recommend relaxation exercises for pain control.
Answer: C
Feedback: Prompt pain management is crucial for clients in sickle cell crisis to alleviate pain and
prevent complications.
10. Patient: Toddler with croup.
Situation: Nurse is monitoring the child.
Question: Which initial sign of croup requires immediate attention?
A) Respiratory rate of 42.
B) Lethargy for the past hour.
C) Apical pulse of 54.
D) Coughing up copious secretions.
Answer: A
Feedback: A high respiratory rate indicates respiratory distress, requiring immediate intervention.
1. Patient: Pre-adolescent in skeletal Dunlop traction.
Situation: The nurse is caring for the child in traction.
Question: What is the appropriate nursing intervention?
A) Ensure the child is in correct body alignment.
B) Make sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort.
D) Release the traction for 15-20 minutes every 6 hours as needed.
Answer: A
Feedback: Proper alignment helps in effective healing and prevents complications.
2. Patient: Healthy child at a 2-year check-up.
Situation: The nurse is assessing the child.
Question: Which finding should be reported immediately to the healthcare provider?
A) Significant variance in height and weight percentiles.
B) Growth pattern appears to have slowed.
C) Recumbent and standing height are different.
D) Short-term weight changes are uneven.
Answer: A
Feedback: Variations can indicate growth or developmental issues requiring further evaluation.
3. Patient: 2-year-old child holding breath during temper tantrums.
Situation: Parents report breath-holding during tantrums.
Question: What is the best action by the nurse?
, A) Teach the parents how to perform cardiopulmonary resuscitation.
B) Recommend that the parents give in when he holds his breath to prevent anoxia.
C) Advise parents to ignore breath-holding as the child will resume breathing naturally.
D) Instruct the parents on how to reason with the child about possible harmful effects.
Answer: C
Feedback: Breath-holding typically resolves without intervention and does not cause long-term harm.
4. Patient: Client in the emergency room.
Situation: The client describes chest pain.
Question: Which statement suggests acute angina?
A) "My pain is deep in my chest behind my sternum."
B) "When I sit up the pain gets worse."
C) "As I take a deep breath the pain gets worse."
D) "The pain is right here in my stomach area."
Answer: A
Feedback: This type of pain location is characteristic of angina, needing immediate attention.
5. Patient: Client with possible organic brain disorder.
Situation: The nurse is assessing mental status.
Question: Which question best assesses recent memory function?
A) "Name the year." "What season is this?" (pause for answer after each question)
B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to
subtract 7 from the new number."
C) "I am going to say three words and I want you to repeat them after me: blue, ball, pen."
D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"
Answer: C
,Feedback: This test evaluates the ability to recall recent information, critical in memory assessment.
6. Patient: 6-month-old infant.
Situation: Planning care for the infant.
Question: What must the nurse provide to assist in developing trust?
A) Food.
B) Warmth.
C) Security.
D) Comfort.
Answer: C
Feedback: Consistent and responsive care helps infants develop a sense of security and trust.
7. Situation: Nurse receives an illegible medication order.
Question: Which statement best reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean."
B) "Could you please clarify what you have written so I am sure I am reading it correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful."
D) "Please print in the future so I do not have to spend extra time attempting to read your writing."
Answer: B
Feedback: Clear communication ensures safe medication administration and patient safety.
8. Situation: Teaching parents to reduce home risks.
Question: What is the most important consideration?
A) Age and knowledge level of the parents.
B) Proximity to emergency services.
, C) Number of children in the home.
D) Age of children in the home.
Answer: D
Feedback: Different ages pose different risks; safety measures should be age-appropriate.
9. Patient: 35-year-old client with sickle cell crisis.
Situation: The client requests pain relief.
Question: What should the nurse do?
A) Administer a placebo.
B) Encourage increased fluid intake.
C) Administer the prescribed analgesic.
D) Recommend relaxation exercises for pain control.
Answer: C
Feedback: Prompt pain management is crucial for clients in sickle cell crisis to alleviate pain and
prevent complications.
10. Patient: Toddler with croup.
Situation: Nurse is monitoring the child.
Question: Which initial sign of croup requires immediate attention?
A) Respiratory rate of 42.
B) Lethargy for the past hour.
C) Apical pulse of 54.
D) Coughing up copious secretions.
Answer: A
Feedback: A high respiratory rate indicates respiratory distress, requiring immediate intervention.
