STUDY FOR EXIT HESI EXAM WITH CORRECT ANSWERS
After receiving IV fluids in the ER, an elderly patient is admitted to the acute care unit with a medical diagnosis
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of dehydration. The patient is receiving 0.9% normal saline 125 mL/hr via saline lock and has a bounding pulse,
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tachycardia, and pedal edema. When contacting the dr, the nurse anticipates a prescription with what
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intervention?
a. Remove the saline lock from the arm
t t t t t t t
b. Increase rate of normal saline
t t t t t
c. Decrease rate of normal saline infusion
t t t t t t
d. Change IV solution to 0.45% saline solution - correct answer a. Remove the saline lock from the arm
t t t t t t t t t t t t t t t t t t
A patient who is admitted to the care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has
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developed osmotic demyelination. Which intervention should the nurse implement first?
t t t t t t t t t t
a. Patch one eye
t t t
b. Evaluate swallow
t t
c. Reorient often
t t
d. Range of motion - correct answer b. Evaluate swallow
t t t t t t t t t
The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge home. Which
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recommendations should the nurse provide this patient? (SATA) t t t t t t t
a. Wash stump with soap and water
t t t t t t
b. Avoid range of motion exercise
t t t t t
c. Apply alcohol to the stump after bathing
t t t t t t t
d. Inspect skin for redness
t t t t
,e. Use a residual limb shrinker - correct answer a. Wash stump with soap and water
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d. Inspect skin for redness
t t t t
e. Use a residual limb shrinker
t t t t t
After 2 days treatment of dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing
t t t t t t t t t t t t t t t t t t
and the child's urine output is 50 mL/hr. During morning assessment, the nurse determines that the child is
t t t t t t t t t t t t t t t t t t
lethargic and difficult to arouse. Which should the nurse implement?
t t t t t t t t t
a. Increase IV fluid flow rate
t t t t t
b. Review 24 hr intake and output
t t t t t t
c. Obtain ABGs
t t
d. Perform a finger stick glucose test - correct answer d. Perform a finger stick glucose test
t t t t t t t t t t t t t t t t
A patient with bleeding esophageal varices receives vasopressin IV. What should the nurse monitor for during
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the IV infusion of this medication?
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a. Vasodilation of the extremities
t t t t
b. Chest pain and dysrhythmia
t t t t
c. Hypotension and tachycardia
t t t
d. Decreasing GI cramping and nausea - correct answer b. Chest pain and dysrhythmia
t t t t t t t t t t t t t
A male patient with an antisocial personality disorder is admitted to an inpatient mental health unit for
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multiple substance dependency. When providing a history, the patient justifies to the nurse his use of drugs.
t t t t t t t t t t t t t t t t t
Based on this pattern of behavior, this patient's history if most likely to include which finding?
t t t t t t t t t t t t t t t
a. Multiple convictions for misdemeanors and Class B felonies
t t t t t t t t
b. Delusions of grandiosity and persecution
t t t t t
c. Suicidal ideations and multiple attempts
t t t t t
,d. Photos and panic attacks when confronted by authority - correct answer a. Multiple convictions for
t t t t t t t t t t t t t t t t
misdemeanors and Class B felonies t t t t
An older patient is admitted for repair of a broken hip. To reduce the risk of infection postoperative period,
t t t t t t t t t t t t t t t t t t t
which nursing care intervention should the nurse include in the patient's plan of care? (SATA)
t t t t t t t t t t t t t t
a. Administer low molecular weight heparin
t t t t t
b. Teach patient to use incentive spirometer every 2 hours while awake
t t t t t t t t t t t
c. Remove urinary catheter as soon as possible and encourage voiding
t t t t t t t t t t
d. Maintain sequential compression devices while in bed
t t t t t t t
e. Assess pain level and medicate PRN as prescribed - correct answer b. Teach patient to use incentive
t t t t t t t t t t t t t t t t t t
spirometer every 2 hours while awake t t t t t
c. Remove urinary catheter as soon possible and encourage voiding
t t t t t t t t t
The nurse is preparing a 50 mL dose of 50% dextrose IV for a patient with insulin shock. How should the nurse
t t t t t t t t t t t t t t t t t t t t t t
administer the medication? t t
a. Dilute dextrose in 1 liter of 0.9% normal saline solution
t t t t t t t t t t
b. Push undiluted slowly through the currently infusing IV
t t t t t t t t
c. Mix dextrose in a 50 mL piggyback for a total volume of 100 mL
t t t t t t t t t t t t t t
d. Ask the pharmacist to add the dextrose to a TPN solution - correct answer b. Push undiluted slowly through
t t t t t t t t t t t t t t t t t t t t
the currently infusing IV
t t t
A patient with arthritis has been receiving treatment with naproxen and now reports stomach pain, increasing
t t t t t t t t t t t t t t t t
weakness, and fatigue. Which lab test should the nurse monitor? t t t t t t t t t
a. Calcium
t
b. Erythrocyte sedimentation rate
t t t
c. Osmolaltiy
t
d. Hemoglobin - correct answer d. Hemoglobin
t t t t t t
, A patient with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse
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that the client is experiencing a therapeutic response to the phenytoin?
t t t t t t t t t t
a. Increased time of ambulation between periods of rest
t t t t t t t t
b. Decrease in intracranial pressure and cerebral edema
t t t t t t t
c. Absence of seizure activity for the duration of treatment
t t t t t t t t t
d. Normal electroencephalogram after drug administration - correct answer c. Absence of seizure activity for
t t t t t t t t t t t t t t t
the duration of treatment
t t t
A patient with peptic ulcer disease receives a prescription for intermittent suction via a salem sump
t t t t t t t t t t t t t t t t
nasogastric tube. After inserting the NGT and obtaining coffee ground gastric contents, the nurse clamps the
t t t t t t t t t t t t t t t t
NGT because the patient must leave the room for diagnostic studies. Upon return to the unit, the patient
t t t t t t t t t t t t t t t t t t
complains of nausea. What action should the nurse implement first? t t t t t t t t t
a. Administering a prescribed antiemetic agent
t t t t t
b. Provide oral suction using a Yankauer tip
t t t t t t t
c. Connect the NGT to low intermittent suction
t t t t t t t
d. Irrigate the NGT with normal saline - correct answer d. Irrigate the NGT with normal saline
t t t t t t t t t t t t t t t t
The healthcare provider prescribes fluid of 0.9 sodium chloride 1,000 mL to be infused over 4 hours. The IV
t t t t t t t t t t t t t t t t t t t
administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion? (round to t t t t t t t t t t t t t t t t
nearest whole number) t t
gtt/min = volume (mL) / time (min) x drop factor (gtt/mL)
t t t t t t t t t t
Flow rate = 1000 mL/240 min x 10 gtt/mL = 41.667 gtt/min - correct answer 42
t t t t t t t t t t t t t t t
At 40 week gestation, a laboring patient who is lying in a supine position tells the nurse that she has finally
t t t t t t t t t t t t t t t t t t t t t
found a comfortable position. What action should the nurse take?
t t t t t t t t t
a. Place pillow under the patient's head and knees
t t t t t t t t
After receiving IV fluids in the ER, an elderly patient is admitted to the acute care unit with a medical diagnosis
t t t t t t t t t t t t t t t t t t t t t
of dehydration. The patient is receiving 0.9% normal saline 125 mL/hr via saline lock and has a bounding pulse,
t t t t t t t t t t t t t t t t t t t
tachycardia, and pedal edema. When contacting the dr, the nurse anticipates a prescription with what
t t t t t t t t t t t t t t t
intervention?
a. Remove the saline lock from the arm
t t t t t t t
b. Increase rate of normal saline
t t t t t
c. Decrease rate of normal saline infusion
t t t t t t
d. Change IV solution to 0.45% saline solution - correct answer a. Remove the saline lock from the arm
t t t t t t t t t t t t t t t t t t
A patient who is admitted to the care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has
t t t t t t t t t t t t t t t t t
developed osmotic demyelination. Which intervention should the nurse implement first?
t t t t t t t t t t
a. Patch one eye
t t t
b. Evaluate swallow
t t
c. Reorient often
t t
d. Range of motion - correct answer b. Evaluate swallow
t t t t t t t t t
The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge home. Which
t t t t t t t t t t t t t t t t
recommendations should the nurse provide this patient? (SATA) t t t t t t t
a. Wash stump with soap and water
t t t t t t
b. Avoid range of motion exercise
t t t t t
c. Apply alcohol to the stump after bathing
t t t t t t t
d. Inspect skin for redness
t t t t
,e. Use a residual limb shrinker - correct answer a. Wash stump with soap and water
t t t t t t t t t t t t t t t
d. Inspect skin for redness
t t t t
e. Use a residual limb shrinker
t t t t t
After 2 days treatment of dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing
t t t t t t t t t t t t t t t t t t
and the child's urine output is 50 mL/hr. During morning assessment, the nurse determines that the child is
t t t t t t t t t t t t t t t t t t
lethargic and difficult to arouse. Which should the nurse implement?
t t t t t t t t t
a. Increase IV fluid flow rate
t t t t t
b. Review 24 hr intake and output
t t t t t t
c. Obtain ABGs
t t
d. Perform a finger stick glucose test - correct answer d. Perform a finger stick glucose test
t t t t t t t t t t t t t t t t
A patient with bleeding esophageal varices receives vasopressin IV. What should the nurse monitor for during
t t t t t t t t t t t t t t t t
the IV infusion of this medication?
t t t t t
a. Vasodilation of the extremities
t t t t
b. Chest pain and dysrhythmia
t t t t
c. Hypotension and tachycardia
t t t
d. Decreasing GI cramping and nausea - correct answer b. Chest pain and dysrhythmia
t t t t t t t t t t t t t
A male patient with an antisocial personality disorder is admitted to an inpatient mental health unit for
t t t t t t t t t t t t t t t t t
multiple substance dependency. When providing a history, the patient justifies to the nurse his use of drugs.
t t t t t t t t t t t t t t t t t
Based on this pattern of behavior, this patient's history if most likely to include which finding?
t t t t t t t t t t t t t t t
a. Multiple convictions for misdemeanors and Class B felonies
t t t t t t t t
b. Delusions of grandiosity and persecution
t t t t t
c. Suicidal ideations and multiple attempts
t t t t t
,d. Photos and panic attacks when confronted by authority - correct answer a. Multiple convictions for
t t t t t t t t t t t t t t t t
misdemeanors and Class B felonies t t t t
An older patient is admitted for repair of a broken hip. To reduce the risk of infection postoperative period,
t t t t t t t t t t t t t t t t t t t
which nursing care intervention should the nurse include in the patient's plan of care? (SATA)
t t t t t t t t t t t t t t
a. Administer low molecular weight heparin
t t t t t
b. Teach patient to use incentive spirometer every 2 hours while awake
t t t t t t t t t t t
c. Remove urinary catheter as soon as possible and encourage voiding
t t t t t t t t t t
d. Maintain sequential compression devices while in bed
t t t t t t t
e. Assess pain level and medicate PRN as prescribed - correct answer b. Teach patient to use incentive
t t t t t t t t t t t t t t t t t t
spirometer every 2 hours while awake t t t t t
c. Remove urinary catheter as soon possible and encourage voiding
t t t t t t t t t
The nurse is preparing a 50 mL dose of 50% dextrose IV for a patient with insulin shock. How should the nurse
t t t t t t t t t t t t t t t t t t t t t t
administer the medication? t t
a. Dilute dextrose in 1 liter of 0.9% normal saline solution
t t t t t t t t t t
b. Push undiluted slowly through the currently infusing IV
t t t t t t t t
c. Mix dextrose in a 50 mL piggyback for a total volume of 100 mL
t t t t t t t t t t t t t t
d. Ask the pharmacist to add the dextrose to a TPN solution - correct answer b. Push undiluted slowly through
t t t t t t t t t t t t t t t t t t t t
the currently infusing IV
t t t
A patient with arthritis has been receiving treatment with naproxen and now reports stomach pain, increasing
t t t t t t t t t t t t t t t t
weakness, and fatigue. Which lab test should the nurse monitor? t t t t t t t t t
a. Calcium
t
b. Erythrocyte sedimentation rate
t t t
c. Osmolaltiy
t
d. Hemoglobin - correct answer d. Hemoglobin
t t t t t t
, A patient with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse
t t t t t t t t t t t t t t t
that the client is experiencing a therapeutic response to the phenytoin?
t t t t t t t t t t
a. Increased time of ambulation between periods of rest
t t t t t t t t
b. Decrease in intracranial pressure and cerebral edema
t t t t t t t
c. Absence of seizure activity for the duration of treatment
t t t t t t t t t
d. Normal electroencephalogram after drug administration - correct answer c. Absence of seizure activity for
t t t t t t t t t t t t t t t
the duration of treatment
t t t
A patient with peptic ulcer disease receives a prescription for intermittent suction via a salem sump
t t t t t t t t t t t t t t t t
nasogastric tube. After inserting the NGT and obtaining coffee ground gastric contents, the nurse clamps the
t t t t t t t t t t t t t t t t
NGT because the patient must leave the room for diagnostic studies. Upon return to the unit, the patient
t t t t t t t t t t t t t t t t t t
complains of nausea. What action should the nurse implement first? t t t t t t t t t
a. Administering a prescribed antiemetic agent
t t t t t
b. Provide oral suction using a Yankauer tip
t t t t t t t
c. Connect the NGT to low intermittent suction
t t t t t t t
d. Irrigate the NGT with normal saline - correct answer d. Irrigate the NGT with normal saline
t t t t t t t t t t t t t t t t
The healthcare provider prescribes fluid of 0.9 sodium chloride 1,000 mL to be infused over 4 hours. The IV
t t t t t t t t t t t t t t t t t t t
administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion? (round to t t t t t t t t t t t t t t t t
nearest whole number) t t
gtt/min = volume (mL) / time (min) x drop factor (gtt/mL)
t t t t t t t t t t
Flow rate = 1000 mL/240 min x 10 gtt/mL = 41.667 gtt/min - correct answer 42
t t t t t t t t t t t t t t t
At 40 week gestation, a laboring patient who is lying in a supine position tells the nurse that she has finally
t t t t t t t t t t t t t t t t t t t t t
found a comfortable position. What action should the nurse take?
t t t t t t t t t
a. Place pillow under the patient's head and knees
t t t t t t t t
