HESI Exit v2 Exam 2024/2025
The nurse knows which statement by the mother indicates that the mother understands safety
precautions with her four month-old infant and her 4year-old child?
A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of
the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocksstuck up in the air
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old bottle in the kitchen
while I make supper." correct answersThe correct answer is D: "I have the four year-old hold and help
feed the four month-old a bottle in the kitchen
Upon completing the admission documents, the nurse learns that the 87 year-old client does not have
an advance directive. What action should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary; correct answersThe correct answer is B: Give information about
advance directives
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization
was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The
nurse expects that the first action in the sequence of
care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered correct answersThe correct answer is B: Administer
epinephrine 1:1000 as ordered .
,Which of these children at the site of a disaster at a child day care center would thea triage nurse put in
the "treat last" category?
A) An infant with intermittent bulging anterior fontanel between crying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
D) A school-age child with singed eyebrows and hair on the arms correct answersThe correct answer is B:
A toddler with severe deep abrasions over 98% of the body .
When admitting a client to an acute care facility, an identification bracelet is sent up with the admission
form. In the event these do not match, the nurse's best action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client correct answersThe correct answer is C: notify
the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's writtenorder that was
written right before the shift change. What action should be taken? A) Leave the order for the oncoming
staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification correct answersThe correct answer is D: Call the provider for
clarification
An adult client is found to be unresponsive on morning rounds. After Checking for responsiveness and
calling for help, the next action that should be taken by the nurse is to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway correct answersThe correct answer is D: open the client''s airway
,A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has
been infused after 4 hours. What is the priority nursing action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs correct answersThe correct answer is D: Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the nurse
see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motorcycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery. correct answersThe correct
answer is C: 72 year-old recovering from surgery after hip replacement 2 hours ago
A nurse observes a family member administer a rectal suppository by having the client lie on the left side
for the administration. The family member pushed the suppository until the finger went up to the
second knuckle. After 10 minutes the client
was told by the family member to turn to the right side and the client did this. What is the
appropriate comment for the nurse to make?
A) Why don't we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the insertion?
C) Let's check to see if the suppository is far enough.
D) Did you feel any stool in the intestinal tract? correct answersThe correct answer is B: That was done
correctly. Did you have any problems with the insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) has
died. Which type of precautions is the appropriate type to use when performing post mortem care?
A) airborne precautions
B) droplet precautions
, C) contact precautions
D) compromised host precautions correct answersThe correct answer is C: contact precautions
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is
appropriate teaching?
A) Void a little, clean the meatus, then collect specimen
B) clean the meatus, begin voiding, then catch urine stream
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine correct answersB) clean the meatus, begin voiding,
then catch urine stream
The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40mg every day. Which of these
foods would the nurse reinforce for the client to eat at least daily?
A) spaghetti
B) watermelon
C) chicken
D) tomatoes correct answersB) watermelon
A nurse is stuck in the hand by an exposed needle. What immediate action should the
Nurse take?
A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management correct answersC) Immediately wash the hands with vigor
As the nurse observes the student nurse during the administration of narcotic analgesic IM injection, the
nurse notes that the student begins to give the medication without first aspirating. What should the
nurse do?
A) Ask the student: "What did you forget to do?"
B) Stop. Tell me why aspiration is needed.
The nurse knows which statement by the mother indicates that the mother understands safety
precautions with her four month-old infant and her 4year-old child?
A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of
the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocksstuck up in the air
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old bottle in the kitchen
while I make supper." correct answersThe correct answer is D: "I have the four year-old hold and help
feed the four month-old a bottle in the kitchen
Upon completing the admission documents, the nurse learns that the 87 year-old client does not have
an advance directive. What action should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary; correct answersThe correct answer is B: Give information about
advance directives
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization
was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The
nurse expects that the first action in the sequence of
care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered correct answersThe correct answer is B: Administer
epinephrine 1:1000 as ordered .
,Which of these children at the site of a disaster at a child day care center would thea triage nurse put in
the "treat last" category?
A) An infant with intermittent bulging anterior fontanel between crying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
D) A school-age child with singed eyebrows and hair on the arms correct answersThe correct answer is B:
A toddler with severe deep abrasions over 98% of the body .
When admitting a client to an acute care facility, an identification bracelet is sent up with the admission
form. In the event these do not match, the nurse's best action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client correct answersThe correct answer is C: notify
the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's writtenorder that was
written right before the shift change. What action should be taken? A) Leave the order for the oncoming
staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification correct answersThe correct answer is D: Call the provider for
clarification
An adult client is found to be unresponsive on morning rounds. After Checking for responsiveness and
calling for help, the next action that should be taken by the nurse is to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway correct answersThe correct answer is D: open the client''s airway
,A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has
been infused after 4 hours. What is the priority nursing action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs correct answersThe correct answer is D: Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the nurse
see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motorcycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery. correct answersThe correct
answer is C: 72 year-old recovering from surgery after hip replacement 2 hours ago
A nurse observes a family member administer a rectal suppository by having the client lie on the left side
for the administration. The family member pushed the suppository until the finger went up to the
second knuckle. After 10 minutes the client
was told by the family member to turn to the right side and the client did this. What is the
appropriate comment for the nurse to make?
A) Why don't we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the insertion?
C) Let's check to see if the suppository is far enough.
D) Did you feel any stool in the intestinal tract? correct answersThe correct answer is B: That was done
correctly. Did you have any problems with the insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) has
died. Which type of precautions is the appropriate type to use when performing post mortem care?
A) airborne precautions
B) droplet precautions
, C) contact precautions
D) compromised host precautions correct answersThe correct answer is C: contact precautions
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is
appropriate teaching?
A) Void a little, clean the meatus, then collect specimen
B) clean the meatus, begin voiding, then catch urine stream
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine correct answersB) clean the meatus, begin voiding,
then catch urine stream
The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40mg every day. Which of these
foods would the nurse reinforce for the client to eat at least daily?
A) spaghetti
B) watermelon
C) chicken
D) tomatoes correct answersB) watermelon
A nurse is stuck in the hand by an exposed needle. What immediate action should the
Nurse take?
A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management correct answersC) Immediately wash the hands with vigor
As the nurse observes the student nurse during the administration of narcotic analgesic IM injection, the
nurse notes that the student begins to give the medication without first aspirating. What should the
nurse do?
A) Ask the student: "What did you forget to do?"
B) Stop. Tell me why aspiration is needed.
