HESI RN Exit Exam
. . .
Following.discharge.teaching,.a.male.client.with.duodenal.ulcer.tells.the.nurse.the.he.w
ill.drink.plenty.of.dairy.products,.such.as.milk,.to.help.coat.and.protect.his.ulcer..What.
is.the.best.follow-up.action.by.the.nurse?
a. Remind.the.client.that.it.is.also.important.to.switch.to.decaffeinated.coffee.and.tea.
b. Suggest.that.the.client.also.plan.to.eat.frequent.small.meals.to.reduce.discomfort
c. Review.with.the.client.the.need.to.avoid.foods.that.are.rich.in.milk.and.cream.
d. Reinforce.this.teaching.by.asking.the.client.to.list.a.dairy.food.that.he.might.sele
ct.
(ANS-.Review.with.the.client.the.need.to.avoid.foods.that.are.rich.in.milk.and.cream
Rationale:.Diets.rich.in.milk.and.cream.stimulate.gastric.acid.secretion.and.should.be.a
voided.
A.male.client.with.hypertension,.who.received.new.antihypertensive.prescriptions.at.
his.last.visit.returns.to.the.clinic.two.weeks.later.to.evaluate.his.blood.pressure.(BP)..H
is.BP.is.158/106.and.he.admits.that.he.has.not.been.taking.the.prescribed.medication.b
ecause.the.drugs.make.him."feel.bad"..In.explaining.the.need.for.hypertension.control
,.the.nurse.should.stress.that.an.elevated.BP.places.the.client.at.risk.for.which.pathoph
ysiological.condition?
a. Blindness.secondary.to.cataracts
b. Acute.kidney.injury.due.to.glomerular.damage
c. Stroke.secondary.to.hemorrhage
d. Heart.block.due.to.myocardial.damage.(
ANS-.Stroke.secondary.to.hemorrhage
Rationale:.Stroke.related.to.cerebral.hemorrhage.is.major.risk.for.uncontrolled.hyperte
nsion.
,The.nurse.observes.an.unlicensed.assistive.personnel.(UAP).positioning.a.newly.adm
itted.client.who.has.a.seizure.disorder..The.client.is.supine.and.the.UAP.is.placing.soft.
pillows.along.the.side.rails..What.action.should.the.nurse.implement?
a. Ensure.that.the.UAP.has.placed.the.pillows.effectively.to.protect.the.client.
b. Instruct.the.UAP.to.obtain.soft.blankets.to.secure.to.the.side.rails.instead.of.pill
ows.
c. Assume.responsibility.for.placing.the.pillows.while.the.UAP.completes.another.ta
sk.
d. Ask.the.UAP.to.use.some.of.the.pillows.to.prop.the.client.in.a.side.lying.posi
tion.
(ANS-
.Instruct.the.UAP.to.obtain.soft.blankets.to.secure.to.the.side.rails.instead.of.pillows
Rationale:.The.nurse.should.instruct.the.UAP.to.pad.the.side.rails.with.soft.blankest.b
ecause.the.use.of.pillows.could.result.in.suffocation.and.would.need.to.be.removed.at.t
he.onset.of.the.seizure..The.nurse.can.delegate.paddling.the.side.rails.to.the.UAP
An.adolescent.with.major.depressive.disorder.has.been.taking.duloxetine.(Cymb
alta).for.the.past.12.days..Which.assessment.finding.requires.immediate.follow-
up
a. Describes.life.without.purpose
b. Complains.of.nausea.and.loss.of.appetite
c. States.is.often.fatigued.and.drowsy
d. Exhibits.an.increase.in.sweating..(A
NS-.Describes.life.without.purpose
Rationale:.Cymbalta.is.a.selective.serotonin.and.norepinephrine.reuptake.inhibitor.tha
t.is.known.to.increase.the.risk.of.suicidal.thinking.in.adolescents.and.young.adults.with
.major.depressive.disorder..B,.C.and.D.are.side.effects
,A.60-year-
old.female.client.with.a.positive.family.history.of.ovarian.cancer.has.developed.an.abd
ominal.mass.and.is.being.evaluated.for.possible.ovarian.cancer..Her.Papanicolau.(Pap)
.smear.results.are.negative..What.information.should.the.nurse.include.in.the.client's.te
aching.plan
a. Further.evaluation.involving.surgery.may.be.needed
b. A.pelvic.exam.is.also.needed.before.cancer.is.ruled.out
c. Pap.smear.evaluation.should.be.continued.every.six.month
d. One.additional.negative.pap.smear.in.six.months.is.needed..(
ANS-.Further.evaluation.involving.surgery.may.be.needed
Rationale:.An.abdominal.mass.in.a.client.with.a.family.history.for.ovarian.cancer.shoul
d.be.evaluated.carefully
A.client.who.recently.underwent.a.tracheostomy.is.being.prepared.for.discharge.to.ho
me..Which.instructions.is.most.important.for.the.nurse.to.include.in.the.discharge.pla
n?
a. Explain.how.to.use.communication.tools.
b. Teach.tracheal.suctioning.techniques
c. Encourage.self-care.and.independence.
d. Demonstrate.how.to.clean.tracheostomy.site..(
ANS-.Teach.tracheal.suctioning.techniques
Rationale:.Suctioning.helps.to.clear.secretions.and.maintain.an.open.airway,.which.is.c
ritical.
In.assessing.an.adult.client.with.a.partial.rebreather.mask,.the.nurse.notes.that.the.oxyg
en.reservoir.bag.does.not.deflate.completely.during.inspiration.and.the.client's.respirat
ory.rate.is.14.breaths./.minute..What.action.should.the.nurse.implement
a. Encourage.the.client.to.take.deep.breaths
b. Remove.the.mask.to.deflate.the.bag
c. Increase.the.liter.flow.of.oxygen
d. Document.the.assessment.data
, (ANS-.Document.the.assessment.data
Rationale:.reservoir.bag.should.not.deflate.completely.during.inspiration.and.the.clien
t's.respiratory.rate.is.within.normal.limits.
During.shift.report,.the.central.electrocardiogram.(EKG).monitoring.system.alarms..
Which.client.alarm.should.the.nurse.investigate.first?
a. Respiratory.apnea.of.30.seconds
b. Oxygen.saturation.rate.of.88%
c. Eight.premature.ventricular.beats.every.minute
d. Disconnected.monitor.signal.for.the.last.6.minutes..(
ANS-.Respiratory.apnea.of.30.seconds
Rationale:.The.priority.is.the.client.whose.alarm.indicating.respiratory.apnea.that.shou
ld.be.assessed.first.
During.a.home.visit,.the.nurse.observed.an.elderly.client.with.diabetes.slip.and.fall..
What.action.should.the.nurse.take.first?
a. Give.the.client.4.ounces.of.orange.juice
b. Call.911.to.summon.emergency.assistance
c. Check.the.client.for.lacerations.or.fractures
d. Asses.clients.blood.sugar.level.(ANS-
.Check.the.client.for.lacerations.or.fractures
Rationale:.After.the.client.falls,.the.nurse.should.immediately.assess.for.the.possibility.
of.injuries.and.provide.first.aid.as.needed
At.0600.while.admitting.a.woman.for.a.schedule.repeat.cesarean.section.(C-
.Section),.the.client.tells.the.nurse.that.she.drank.a.cup.a.coffee.at.0400.because.she.wan
ted.to.avoid.getting.a.headache..Which.action.should.the.nurse.take.first?
a. Ensure.preoperative.lab.results.are.available
b. Start.prescribed.IV.with.lactated.Ringer's
. . .
Following.discharge.teaching,.a.male.client.with.duodenal.ulcer.tells.the.nurse.the.he.w
ill.drink.plenty.of.dairy.products,.such.as.milk,.to.help.coat.and.protect.his.ulcer..What.
is.the.best.follow-up.action.by.the.nurse?
a. Remind.the.client.that.it.is.also.important.to.switch.to.decaffeinated.coffee.and.tea.
b. Suggest.that.the.client.also.plan.to.eat.frequent.small.meals.to.reduce.discomfort
c. Review.with.the.client.the.need.to.avoid.foods.that.are.rich.in.milk.and.cream.
d. Reinforce.this.teaching.by.asking.the.client.to.list.a.dairy.food.that.he.might.sele
ct.
(ANS-.Review.with.the.client.the.need.to.avoid.foods.that.are.rich.in.milk.and.cream
Rationale:.Diets.rich.in.milk.and.cream.stimulate.gastric.acid.secretion.and.should.be.a
voided.
A.male.client.with.hypertension,.who.received.new.antihypertensive.prescriptions.at.
his.last.visit.returns.to.the.clinic.two.weeks.later.to.evaluate.his.blood.pressure.(BP)..H
is.BP.is.158/106.and.he.admits.that.he.has.not.been.taking.the.prescribed.medication.b
ecause.the.drugs.make.him."feel.bad"..In.explaining.the.need.for.hypertension.control
,.the.nurse.should.stress.that.an.elevated.BP.places.the.client.at.risk.for.which.pathoph
ysiological.condition?
a. Blindness.secondary.to.cataracts
b. Acute.kidney.injury.due.to.glomerular.damage
c. Stroke.secondary.to.hemorrhage
d. Heart.block.due.to.myocardial.damage.(
ANS-.Stroke.secondary.to.hemorrhage
Rationale:.Stroke.related.to.cerebral.hemorrhage.is.major.risk.for.uncontrolled.hyperte
nsion.
,The.nurse.observes.an.unlicensed.assistive.personnel.(UAP).positioning.a.newly.adm
itted.client.who.has.a.seizure.disorder..The.client.is.supine.and.the.UAP.is.placing.soft.
pillows.along.the.side.rails..What.action.should.the.nurse.implement?
a. Ensure.that.the.UAP.has.placed.the.pillows.effectively.to.protect.the.client.
b. Instruct.the.UAP.to.obtain.soft.blankets.to.secure.to.the.side.rails.instead.of.pill
ows.
c. Assume.responsibility.for.placing.the.pillows.while.the.UAP.completes.another.ta
sk.
d. Ask.the.UAP.to.use.some.of.the.pillows.to.prop.the.client.in.a.side.lying.posi
tion.
(ANS-
.Instruct.the.UAP.to.obtain.soft.blankets.to.secure.to.the.side.rails.instead.of.pillows
Rationale:.The.nurse.should.instruct.the.UAP.to.pad.the.side.rails.with.soft.blankest.b
ecause.the.use.of.pillows.could.result.in.suffocation.and.would.need.to.be.removed.at.t
he.onset.of.the.seizure..The.nurse.can.delegate.paddling.the.side.rails.to.the.UAP
An.adolescent.with.major.depressive.disorder.has.been.taking.duloxetine.(Cymb
alta).for.the.past.12.days..Which.assessment.finding.requires.immediate.follow-
up
a. Describes.life.without.purpose
b. Complains.of.nausea.and.loss.of.appetite
c. States.is.often.fatigued.and.drowsy
d. Exhibits.an.increase.in.sweating..(A
NS-.Describes.life.without.purpose
Rationale:.Cymbalta.is.a.selective.serotonin.and.norepinephrine.reuptake.inhibitor.tha
t.is.known.to.increase.the.risk.of.suicidal.thinking.in.adolescents.and.young.adults.with
.major.depressive.disorder..B,.C.and.D.are.side.effects
,A.60-year-
old.female.client.with.a.positive.family.history.of.ovarian.cancer.has.developed.an.abd
ominal.mass.and.is.being.evaluated.for.possible.ovarian.cancer..Her.Papanicolau.(Pap)
.smear.results.are.negative..What.information.should.the.nurse.include.in.the.client's.te
aching.plan
a. Further.evaluation.involving.surgery.may.be.needed
b. A.pelvic.exam.is.also.needed.before.cancer.is.ruled.out
c. Pap.smear.evaluation.should.be.continued.every.six.month
d. One.additional.negative.pap.smear.in.six.months.is.needed..(
ANS-.Further.evaluation.involving.surgery.may.be.needed
Rationale:.An.abdominal.mass.in.a.client.with.a.family.history.for.ovarian.cancer.shoul
d.be.evaluated.carefully
A.client.who.recently.underwent.a.tracheostomy.is.being.prepared.for.discharge.to.ho
me..Which.instructions.is.most.important.for.the.nurse.to.include.in.the.discharge.pla
n?
a. Explain.how.to.use.communication.tools.
b. Teach.tracheal.suctioning.techniques
c. Encourage.self-care.and.independence.
d. Demonstrate.how.to.clean.tracheostomy.site..(
ANS-.Teach.tracheal.suctioning.techniques
Rationale:.Suctioning.helps.to.clear.secretions.and.maintain.an.open.airway,.which.is.c
ritical.
In.assessing.an.adult.client.with.a.partial.rebreather.mask,.the.nurse.notes.that.the.oxyg
en.reservoir.bag.does.not.deflate.completely.during.inspiration.and.the.client's.respirat
ory.rate.is.14.breaths./.minute..What.action.should.the.nurse.implement
a. Encourage.the.client.to.take.deep.breaths
b. Remove.the.mask.to.deflate.the.bag
c. Increase.the.liter.flow.of.oxygen
d. Document.the.assessment.data
, (ANS-.Document.the.assessment.data
Rationale:.reservoir.bag.should.not.deflate.completely.during.inspiration.and.the.clien
t's.respiratory.rate.is.within.normal.limits.
During.shift.report,.the.central.electrocardiogram.(EKG).monitoring.system.alarms..
Which.client.alarm.should.the.nurse.investigate.first?
a. Respiratory.apnea.of.30.seconds
b. Oxygen.saturation.rate.of.88%
c. Eight.premature.ventricular.beats.every.minute
d. Disconnected.monitor.signal.for.the.last.6.minutes..(
ANS-.Respiratory.apnea.of.30.seconds
Rationale:.The.priority.is.the.client.whose.alarm.indicating.respiratory.apnea.that.shou
ld.be.assessed.first.
During.a.home.visit,.the.nurse.observed.an.elderly.client.with.diabetes.slip.and.fall..
What.action.should.the.nurse.take.first?
a. Give.the.client.4.ounces.of.orange.juice
b. Call.911.to.summon.emergency.assistance
c. Check.the.client.for.lacerations.or.fractures
d. Asses.clients.blood.sugar.level.(ANS-
.Check.the.client.for.lacerations.or.fractures
Rationale:.After.the.client.falls,.the.nurse.should.immediately.assess.for.the.possibility.
of.injuries.and.provide.first.aid.as.needed
At.0600.while.admitting.a.woman.for.a.schedule.repeat.cesarean.section.(C-
.Section),.the.client.tells.the.nurse.that.she.drank.a.cup.a.coffee.at.0400.because.she.wan
ted.to.avoid.getting.a.headache..Which.action.should.the.nurse.take.first?
a. Ensure.preoperative.lab.results.are.available
b. Start.prescribed.IV.with.lactated.Ringer's
