EXIT HESI - COMPREHENSIVE PN EXAM
PRACTICE QUESTIONS AND ANSWERS
(GRADED A+!!
Aknursekwhokhaskrecentlykcompletedkorientationkiskbeginningkworkkinktheklaborkandkdelive
rykunitkforkthekfirstktime.kWhenkmakingkassignments,kwhichkclientkshouldkthekchargeknurse
kassignktokthisknewknurse?k-kCORRECTkANSWER-
Akmultiparouskclientkwhokiskdilatedk5kcmkandk50%keffaced
Akclientkwithkhumankimmunodeficiencykvirusk(HIV)kinfectionkhaskwhiteklesionskinkthekoralkc
avitykthatkresemblekmilkkcurds.kNystatink(Mycostatin)kpreparationkiskprescribedkaskakswish
kandkswallow.kWhichkinformationkiskmostkimportantkforktheknursektokprovidekthekclient?k-
kCORRECTkANSWER-Oralkhygienekshouldkbekperformedkbeforekthekmedication.
Akclientkwhokiskadmittedkwithkemphysemakiskhavingkdifficultykbreathing.kInkwhichkpositionk
shouldktheknursekplacekthekclient?k-kCORRECTkANSWER-
Sittingkuprightkandkforwardkwithkbothkarmsksupportedkonkankoverkthekbedktable
Akclientkwithkchronickrenalkinsufficiencyk(CRI)kisktakingk25kmgkofkhydrochlorothiazidek(HC
TZ)kPOkandk40kmgkofkfurosemidek(Lasix)kPOkdaily.kToday,katkakroutinekclinickvisit,kthekclie
nt'skserumkpotassiumklevelkisk4kmEq/L.kWhatkiskthekmostklikelykcausekofkthiskclient'skpotas
siumklevel?k-kCORRECTkANSWER-
Thekclient'skrenalkfunctionkhaskaffectedkhiskpotassiumklevel.
Akregisteredknursek(RN)kdeliversktelehealthkservicesktokclientskviakelectronickcommunicati
on.kWhichknursingkactionkcreateskthekgreatestkriskkforkprofessionalkliabilitykandkhaskthekpo
tentialkforkakmalpracticeklawsuit?k-kCORRECTkANSWER-
SendingkmedicalkrecordsktokhealthkcarekproviderskviakthekInternet
Whichkpathophysiologickresponseksupportskthekcontraindicationkforkopioids,ksuchkaskmor
phine,kinkclientskwithkincreasedkintracranialkpressurek(ICP)?
A.Sedationkproducedkbykopioidskiskakresultkofkakprolongedkhalf-
lifekwhenkthekICPkiskelevated.
kB.Higherkdoseskofkopioidskarekrequiredkwhenkcerebralkbloodkflowkiskreducedkbykankelevat
edkICP.
kC.Dysphoriakfromkopioidskcontributesktokalteredklevelskofkconsciousnesskwithkankelevate
dkICP.
D.Opioidsksuppresskrespirations,kwhichkincreaseskPco2kandkcontributesktokankelevatedkI
CP.k-kCORRECTkANSWER-D
,Thekgreatestkriskkassociatedkwithkopioidsksuchkaskmorphinek(D)kiskrespiratorykdepressionk
thatkcauseskankincreasekinkPco2,kwhichkincreaseskICPkandkmaskskthekearlyksignskofkintra
cranialkbleedingkinkheadkinjury.k(A,kB,kandkC)kdoknotksupportkthekriskskassociatedkwithkopi
oidkusekinkakclientkwithkincreasedkICP.
Thekchargeknursekofkakmedicalksurgicalkunitkiskalertedktokankimpendingkdisasterkrequiringki
mplementationkofkthekhospital'skdisasterkplan.kSpecifickfactskaboutktheknaturekofkthiskdisas
terkareknotkyetkknown.kWhichkinstructionkshouldkthekchargeknursekgivektokthekotherkstaffkm
emberskatkthisktime?
A.Preparektokevacuatekthekunit,kstartingkwithkthekbedriddenkclients.
kB.UAPskshouldkreportktokthekemergencykcenterktokhandlektransports.
kC.TheklicensedkstaffkshouldkbeginkcountingkwheelchairskandkIVkpoleskonkthekunit.
kD.Continuekwithkcurrentkassignmentskuntilkmorekinstructionskarekreceived.k-
kCORRECTkANSWER-D
Whenkfacedkwithkankimpendingkdisaster,khospitalkpersonnelkmaykbekalertedkbutkshouldkco
ntinuekwithkcurrentkclientkcarekassignmentskuntilkfurtherkinstructionskarekreceivedk(D).kEva
cuationkisktypicallykakresponsekofklastkresortkthatkbeginskwithkclientskwhokarekmostkablektok
ambulatek(A).k(B)kiskprematurekandkisklikelyktokincreasekthekchaoskifkincomingkcasualtieska
rekanticipated.k(C)kiskpoorkutilizationkofkpersonnel.
TheknursekassesseskakclientkwhilekthekUAPkmeasureskthekclient'skvitalksigns.kThekclient'sk
vitalksignskchangeksuddenly,kandktheknursekdetermineskthatkthekclient'skconditionkiskworse
ning.kTheknursekiskunsurekofkthekclient'skresuscitativekstatuskandkneedsktokcheckkthekclient
'skmedicalkrecordkforkanykadvancedkdirectives.kWhichkactionkshouldktheknursekimplement
?
A.AskkthekUAPktokcheckkforkthekadvancedkdirectivekwhilektheknursekcompleteskthekassess
ment.
B.AssignkthekUAPktokcompletekthekassessmentkwhilektheknursekcheckskforkthekadvancedk
directive.
C.Checkkthekmedicalkrecordkforkthekadvancedkdirectivekandkthenkcompletekthekclientkasse
ssment.
kD.Callkforkthekchargeknursektokcheckkthekadvancedkdirectivekwhilekcontinuingktokassesskt
hekclient.k-kCORRECTkANSWER-D
Becausekthekclient'skconditionkiskworsening,ktheknursekshouldkremainkwithkthekclientkandkc
ontinuekthekassessmentkwhilekcallingkforkhelpkfromkthekchargeknursektokdeterminekthekclie
nt'skresuscitativekstatusk(D).k(AkandkB)karektaskskthatkmustkbekcompletedkbykaknursekandkc
annotkbekdelegatedktokthekUAP.k(C)kiskcontraindicated.
Theknursekiskpreparingkakclientkforksurgerykscheduledkink2khours.kAkUAPkiskhelpingktheknur
se.kWhichktaskkiskimportantkforktheknursektokperform,kratherkthankthekUAP?
A.Removekthekclient'sknailkpolishkandkdentures.
kB.Assistkthekclientktokthekrestroomktokvoid.
kC.Obtainkthekclient'skheightkandkweight.
, kD.Offerkthekclientkemotionalksupport.k-kCORRECTkANSWER-D
Bykusingktherapeuticktechniquesktokofferksupportk(D),ktheknursekcankdeterminekanykclientk
concernskthatkneedktokbekaddressed.k(A,kB,kandkC)karekallkactionskthatkcankbekperformedk
bykthekUAPkunderktheksupervisionkofktheknurse.
Untilkthekcensuskonkthekobstetricsk(OB)kunitkincreases,kankunlicensedkassistivekpersonnelk
(UAP)kwhokusuallykworkskinklaborkandkdeliverykandktheknewbornknurserykiskassignedktokw
orkkonkthekpostoperativekunit.kWhichkclientkwouldkbekbestkforkthekchargeknursektokassignkt
okthiskUAP?
kA.Ankadolescentkwhokwaskreadmittedktokthekhospitalkbecausekofkakpostoperativekinfectio
n
kB.Akwomankwithkaknewkcolostomykwhokrequireskdischargekteaching
kC.Akwomankwhokhadkakhipkreplacementkandkmaykbektransferredktokthekhomekcarekunit
kD.Akmankwhokhadkakcholecystectomykandkcurrentlykhaskaknasogastricktubeksetktokintermit
tentksuctionk-kCORRECTkANSWER-C
Thekchargeknursekwillkbekresponsiblekforkprovidingkakreportktokthekhomekcarekunitkifkthektra
nsferkoccursk(A).kThekclientkiskinfectedkandkankemployeekwhokworkskonkankOBkunitkshould
kbekassignedktokcleankcaseskinkcasekthekemployeekiskrequiredktokreturnktokthekOBkunitk(B).
kThiskrequireskthekskillskofkakregisteredknursek(RN)ktokdokdischargekteachingkandkprovidek
emotionalksupportk(D).kThiskmaykrequirekskillskbeyondktheklevelkofkthiskUAP.
Akmalekclientkiskadmittedkforkobservationkafterkbeingkhitkonkthekheadkwithkakbaseballkbat.kS
ixkhourskafterkadmission,kthekclientkattemptsktokcrawlkoutkofkbedkandkasksktheknursekwhykt
herekareksokmanykbugskinkhiskbed.kHiskvitalksignskarekstable,kandkthekpulsekoximeterkreadi
ngkisk98%konkroomkair.kWhichkinterventionkshouldktheknursekperformkfirst?
A.Administerkoxygenkperknasalkcannulakatk2kL/min.
B.Planktokcheckkhiskvitalksignskagainkink30kminutes.
C.Notifykthekhealthkcarekproviderkofkthekchangekinkmentalkstatus.
D.Askkthekclientkwhykhekthinksktherekarekbugskinkthekbed.k-kCORRECTkANSWER-C
Onekofkthekearliestksignskofkincreasedkintracranialkpressurek(ICP)kiskakchangekinkmentalkst
atusk(C).kItkiskimportantktokactkearlykandkquicklykwhenksymptomskofkincreasedkICPkoccur.k
Becausekhiskoxygenksaturationkisknormal,kthekadministrationkofkoxygenk(A)kisknotkthektopk
priority.kVitalksignskshouldkbekmonitoredkfrequentlyk(B),kbutkthekclient'skconfusionkshouldkb
ekreportedkimmediately.k(D)kisknotkakusefulkintervention.
Theknursekiskmonitoringkakclientkwhokiskreceivingkbedsidekconsciousksedationkwithkmidaz
olamkhydrochloridek(Versed).kInkassessingkthekclient,ktheknursekdetermineskthatkthekclient
khaskslurredkspeechkwithkdiplopia.kBasedkonkthiskfinding,kwhatkactionkshouldktheknursektak
e?
kA.Openkthekairwaykwithkakchinklift-headktiltkmaneuver.
kB.Obtainkakfingerstickkglucosekreading.
kC.Administerkflumazenilk(Romazicon).
kD.Continuektokmonitorkthekclient.k-kCORRECTkANSWER-D
PRACTICE QUESTIONS AND ANSWERS
(GRADED A+!!
Aknursekwhokhaskrecentlykcompletedkorientationkiskbeginningkworkkinktheklaborkandkdelive
rykunitkforkthekfirstktime.kWhenkmakingkassignments,kwhichkclientkshouldkthekchargeknurse
kassignktokthisknewknurse?k-kCORRECTkANSWER-
Akmultiparouskclientkwhokiskdilatedk5kcmkandk50%keffaced
Akclientkwithkhumankimmunodeficiencykvirusk(HIV)kinfectionkhaskwhiteklesionskinkthekoralkc
avitykthatkresemblekmilkkcurds.kNystatink(Mycostatin)kpreparationkiskprescribedkaskakswish
kandkswallow.kWhichkinformationkiskmostkimportantkforktheknursektokprovidekthekclient?k-
kCORRECTkANSWER-Oralkhygienekshouldkbekperformedkbeforekthekmedication.
Akclientkwhokiskadmittedkwithkemphysemakiskhavingkdifficultykbreathing.kInkwhichkpositionk
shouldktheknursekplacekthekclient?k-kCORRECTkANSWER-
Sittingkuprightkandkforwardkwithkbothkarmsksupportedkonkankoverkthekbedktable
Akclientkwithkchronickrenalkinsufficiencyk(CRI)kisktakingk25kmgkofkhydrochlorothiazidek(HC
TZ)kPOkandk40kmgkofkfurosemidek(Lasix)kPOkdaily.kToday,katkakroutinekclinickvisit,kthekclie
nt'skserumkpotassiumklevelkisk4kmEq/L.kWhatkiskthekmostklikelykcausekofkthiskclient'skpotas
siumklevel?k-kCORRECTkANSWER-
Thekclient'skrenalkfunctionkhaskaffectedkhiskpotassiumklevel.
Akregisteredknursek(RN)kdeliversktelehealthkservicesktokclientskviakelectronickcommunicati
on.kWhichknursingkactionkcreateskthekgreatestkriskkforkprofessionalkliabilitykandkhaskthekpo
tentialkforkakmalpracticeklawsuit?k-kCORRECTkANSWER-
SendingkmedicalkrecordsktokhealthkcarekproviderskviakthekInternet
Whichkpathophysiologickresponseksupportskthekcontraindicationkforkopioids,ksuchkaskmor
phine,kinkclientskwithkincreasedkintracranialkpressurek(ICP)?
A.Sedationkproducedkbykopioidskiskakresultkofkakprolongedkhalf-
lifekwhenkthekICPkiskelevated.
kB.Higherkdoseskofkopioidskarekrequiredkwhenkcerebralkbloodkflowkiskreducedkbykankelevat
edkICP.
kC.Dysphoriakfromkopioidskcontributesktokalteredklevelskofkconsciousnesskwithkankelevate
dkICP.
D.Opioidsksuppresskrespirations,kwhichkincreaseskPco2kandkcontributesktokankelevatedkI
CP.k-kCORRECTkANSWER-D
,Thekgreatestkriskkassociatedkwithkopioidsksuchkaskmorphinek(D)kiskrespiratorykdepressionk
thatkcauseskankincreasekinkPco2,kwhichkincreaseskICPkandkmaskskthekearlyksignskofkintra
cranialkbleedingkinkheadkinjury.k(A,kB,kandkC)kdoknotksupportkthekriskskassociatedkwithkopi
oidkusekinkakclientkwithkincreasedkICP.
Thekchargeknursekofkakmedicalksurgicalkunitkiskalertedktokankimpendingkdisasterkrequiringki
mplementationkofkthekhospital'skdisasterkplan.kSpecifickfactskaboutktheknaturekofkthiskdisas
terkareknotkyetkknown.kWhichkinstructionkshouldkthekchargeknursekgivektokthekotherkstaffkm
emberskatkthisktime?
A.Preparektokevacuatekthekunit,kstartingkwithkthekbedriddenkclients.
kB.UAPskshouldkreportktokthekemergencykcenterktokhandlektransports.
kC.TheklicensedkstaffkshouldkbeginkcountingkwheelchairskandkIVkpoleskonkthekunit.
kD.Continuekwithkcurrentkassignmentskuntilkmorekinstructionskarekreceived.k-
kCORRECTkANSWER-D
Whenkfacedkwithkankimpendingkdisaster,khospitalkpersonnelkmaykbekalertedkbutkshouldkco
ntinuekwithkcurrentkclientkcarekassignmentskuntilkfurtherkinstructionskarekreceivedk(D).kEva
cuationkisktypicallykakresponsekofklastkresortkthatkbeginskwithkclientskwhokarekmostkablektok
ambulatek(A).k(B)kiskprematurekandkisklikelyktokincreasekthekchaoskifkincomingkcasualtieska
rekanticipated.k(C)kiskpoorkutilizationkofkpersonnel.
TheknursekassesseskakclientkwhilekthekUAPkmeasureskthekclient'skvitalksigns.kThekclient'sk
vitalksignskchangeksuddenly,kandktheknursekdetermineskthatkthekclient'skconditionkiskworse
ning.kTheknursekiskunsurekofkthekclient'skresuscitativekstatuskandkneedsktokcheckkthekclient
'skmedicalkrecordkforkanykadvancedkdirectives.kWhichkactionkshouldktheknursekimplement
?
A.AskkthekUAPktokcheckkforkthekadvancedkdirectivekwhilektheknursekcompleteskthekassess
ment.
B.AssignkthekUAPktokcompletekthekassessmentkwhilektheknursekcheckskforkthekadvancedk
directive.
C.Checkkthekmedicalkrecordkforkthekadvancedkdirectivekandkthenkcompletekthekclientkasse
ssment.
kD.Callkforkthekchargeknursektokcheckkthekadvancedkdirectivekwhilekcontinuingktokassesskt
hekclient.k-kCORRECTkANSWER-D
Becausekthekclient'skconditionkiskworsening,ktheknursekshouldkremainkwithkthekclientkandkc
ontinuekthekassessmentkwhilekcallingkforkhelpkfromkthekchargeknursektokdeterminekthekclie
nt'skresuscitativekstatusk(D).k(AkandkB)karektaskskthatkmustkbekcompletedkbykaknursekandkc
annotkbekdelegatedktokthekUAP.k(C)kiskcontraindicated.
Theknursekiskpreparingkakclientkforksurgerykscheduledkink2khours.kAkUAPkiskhelpingktheknur
se.kWhichktaskkiskimportantkforktheknursektokperform,kratherkthankthekUAP?
A.Removekthekclient'sknailkpolishkandkdentures.
kB.Assistkthekclientktokthekrestroomktokvoid.
kC.Obtainkthekclient'skheightkandkweight.
, kD.Offerkthekclientkemotionalksupport.k-kCORRECTkANSWER-D
Bykusingktherapeuticktechniquesktokofferksupportk(D),ktheknursekcankdeterminekanykclientk
concernskthatkneedktokbekaddressed.k(A,kB,kandkC)karekallkactionskthatkcankbekperformedk
bykthekUAPkunderktheksupervisionkofktheknurse.
Untilkthekcensuskonkthekobstetricsk(OB)kunitkincreases,kankunlicensedkassistivekpersonnelk
(UAP)kwhokusuallykworkskinklaborkandkdeliverykandktheknewbornknurserykiskassignedktokw
orkkonkthekpostoperativekunit.kWhichkclientkwouldkbekbestkforkthekchargeknursektokassignkt
okthiskUAP?
kA.Ankadolescentkwhokwaskreadmittedktokthekhospitalkbecausekofkakpostoperativekinfectio
n
kB.Akwomankwithkaknewkcolostomykwhokrequireskdischargekteaching
kC.Akwomankwhokhadkakhipkreplacementkandkmaykbektransferredktokthekhomekcarekunit
kD.Akmankwhokhadkakcholecystectomykandkcurrentlykhaskaknasogastricktubeksetktokintermit
tentksuctionk-kCORRECTkANSWER-C
Thekchargeknursekwillkbekresponsiblekforkprovidingkakreportktokthekhomekcarekunitkifkthektra
nsferkoccursk(A).kThekclientkiskinfectedkandkankemployeekwhokworkskonkankOBkunitkshould
kbekassignedktokcleankcaseskinkcasekthekemployeekiskrequiredktokreturnktokthekOBkunitk(B).
kThiskrequireskthekskillskofkakregisteredknursek(RN)ktokdokdischargekteachingkandkprovidek
emotionalksupportk(D).kThiskmaykrequirekskillskbeyondktheklevelkofkthiskUAP.
Akmalekclientkiskadmittedkforkobservationkafterkbeingkhitkonkthekheadkwithkakbaseballkbat.kS
ixkhourskafterkadmission,kthekclientkattemptsktokcrawlkoutkofkbedkandkasksktheknursekwhykt
herekareksokmanykbugskinkhiskbed.kHiskvitalksignskarekstable,kandkthekpulsekoximeterkreadi
ngkisk98%konkroomkair.kWhichkinterventionkshouldktheknursekperformkfirst?
A.Administerkoxygenkperknasalkcannulakatk2kL/min.
B.Planktokcheckkhiskvitalksignskagainkink30kminutes.
C.Notifykthekhealthkcarekproviderkofkthekchangekinkmentalkstatus.
D.Askkthekclientkwhykhekthinksktherekarekbugskinkthekbed.k-kCORRECTkANSWER-C
Onekofkthekearliestksignskofkincreasedkintracranialkpressurek(ICP)kiskakchangekinkmentalkst
atusk(C).kItkiskimportantktokactkearlykandkquicklykwhenksymptomskofkincreasedkICPkoccur.k
Becausekhiskoxygenksaturationkisknormal,kthekadministrationkofkoxygenk(A)kisknotkthektopk
priority.kVitalksignskshouldkbekmonitoredkfrequentlyk(B),kbutkthekclient'skconfusionkshouldkb
ekreportedkimmediately.k(D)kisknotkakusefulkintervention.
Theknursekiskmonitoringkakclientkwhokiskreceivingkbedsidekconsciousksedationkwithkmidaz
olamkhydrochloridek(Versed).kInkassessingkthekclient,ktheknursekdetermineskthatkthekclient
khaskslurredkspeechkwithkdiplopia.kBasedkonkthiskfinding,kwhatkactionkshouldktheknursektak
e?
kA.Openkthekairwaykwithkakchinklift-headktiltkmaneuver.
kB.Obtainkakfingerstickkglucosekreading.
kC.Administerkflumazenilk(Romazicon).
kD.Continuektokmonitorkthekclient.k-kCORRECTkANSWER-D
