ACTUAL HESI RN 2024 EXIT EXAM
The nurse has completed the diet teaching of a client who is being discharged following
treatment of a leg wound. A high-protein diet is encouraged to promote wound healing.
Which lunch toys by the client indicates that the teaching was effective?
A) A peanut butter sandwich with soda and cookies.
B) Vegetable soup, crackers, and milk.
C) A tuna fish sandwich with chips and ice cream.
D) A salad with three kinds of lettuce and fruit. CORRECT ANSWER: C) A tuna fish
sandwich with chips and ice cream.
A client with foul-smelling drainage from an incision on the upper left arm is admitted
with a suspected MRSA. Which nursing intervention should the nurse include in the
plan of care? SATA.
A) Institute contact precautions for staff and visitors.
B) Use standard precautions and wear a mask.
C) Send wound drainage for culture and sensitivity.
D) Monitor the clients white blood cell count.
E) Explain the purpose of a low bacteria diet. CORRECT ANSWER: A) Institute
contact precautions for staff and visitors.
C) Send wound drainage for culture and sensitivity.
D) Monitor the clients white blood cell count.
An adult client who is admitted to the mental health unit for treatment of bipolar
disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment
finding is most important for the nurse to report to the healthcare provider?
A) Weight loss of 10 pounds in the past month.
B) Six hours of sleep in the past three days.
C) Blood alcohol level of 0.09%.
D) Serum lithium level of 1.6. CORRECT ANSWER: D) Serum lithium level of 1.6.
When conducting diet teaching for a client who is on a post operative full liquid diet,
which foods should the nurse encouraged the client to eat? SATA.
A) Clear beef broth.
B) Vanilla frozen yogurt.
C) Vegetable juice.
D) Creamy peanut butter.
E) Canned fruit cocktail. CORRECT ANSWER: A) Clear beef broth.
B) Vanilla frozen yogurt.
C) Vegetable juice.
,An infant born with esophageal atresia and tracheoesophageal fistula receives a
prescription for internal feedings after corrective surgery. To promote normal growth
and development of the infant, which action should the nurse include in the plan of
care? CORRECT ANSWER: Offer a pacifier for non-Nutritive sucking
The nurse is preparing a four year-old client with a serum bilirubin level of 19 for
discharge from the hospital. When teaching the parents about home photo therapy,
which instruction should the nurse include in the discharge teaching plan?
A) Cover with a receiving blanket.
B) Perform diaper changes under the light.
C) Feed the infant every four hours.
D) Reposition the infant every two hours. CORRECT ANSWER: D) Reposition the
infant every two hours.
When preparing to administer a prescribed medication to a homeless client at a
community psychiatric clinic. The client tells the nurse that the usual dosage taken is
different from the dose the nurse is giving. Which action should the nurse take?
A) Inform the client that he may refuse the medication and document whether or not
the client takes it.
B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at the next healthcare
team meeting. CORRECT ANSWER: B) Withhold the medication until the dosage can
be confirmed.
The charge nurse is making assignments for one practical nurse and three registered
nurses who are caring for neurologically compromised clients. Which client with which
change in status is best to assign to the PN?
A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10 to 7.
D) Myxedema, whose blood pressure change from 80/50 to 70/40. CORRECT
ANSWER: B) Viral meningitis whose temperature change from 101 S to 102F.
The nurse is caring for a client with pneumonia who now develops initial signs of septic
shock and multi organ failure. The healthcare provider prescribes a sepsis protocol.
Which intervention is most important for the nurse to include in the plan of care?
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level. CORRECT ANSWER: A) Maintain strict intake and
output.
,And adolescent client is admitted to the hospital because of writing a suicide note to a
teacher at school. On the second day of hospitalization, the nurse asked the client to
meet with the treatment team. After the team meeting, the client leaves in tears and
goes to their room. Which nursing intervention is best?
A) Let the client rest quietly in their room for a while.
B) Explore the clients goals and desire for treatment.
C) Ask the treatment team about the clients behavior.
D) Go to the clients room and ask what happened. CORRECT ANSWER: D) Go to the
clients room and ask what happened.
The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous
once a day for a client who weighs 154 pounds. The medication is available and 25,000
units per milliliter vial. How many milliliters should the nurse administer? (Enter
numerical value only. If rounding is required, round to the nearest 10th.) CORRECT
ANSWER: 0.6
NGN: The client is a 49-year-old male who reports flu like symptoms including fever
and chest congestion for four days. He came to the emergency department last night
when he was having more difficulty breathing he has a history of 1/2 pack a day cigarette
smoking for 20 years. He has no significant medical or surgical history.
Which two orders should the nurse complete first?
A) Sputum culture.
B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
D) Chest x-ray.
E) Acetominophen 350 mg PO every six hours for temperature control.
F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.
G) Start peripheral IV.
H) NPO. CORRECT ANSWER: B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
NGN: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start
a peripheral IV infusion, start oxygen 3 L per minute via nasal cannula, begin 0.9%
sodium chloride IV infusion at 150 mL per hour, acetaminophen 350 mg PO every six
hours for temperature.
To start the client on oxygen as ordered which items should the nurse collects from the
supply room? SATA
A) humidifier bottle.
B)Suction canister.
C)Sterile water.
D) Nasal cannula.
E) Flow meter.
F) Lambs wool.
G) Tape. CORRECT ANSWER: D) Nasal cannula.
E) Flow meter.
, NGN: states, I am feeling extremely anxious right now. The client has decreased breath
sounds in the left lower low. His mucus membranes are dry. He has a productive cough
with thick, yellow secretions. His capillary refill is four seconds. Vital signs, temperature
100.2. Heart rate 101 bpm, respiratory rate 28 breaths per minute, blood pressure
145/89, oxygen saturation 90% on room air.
(for each body system click to specify the assessment findings that indicates hypoxia)
Cardiovascular: heart rate 100 bpm, capillary refill for seconds, blood pressure 145/89.
Neurological: anxious, awake and alert, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm, productive
cough. CORRECT ANSWER: Cardiovascular: capillary refill for seconds, blood
pressure 145/89.
Neurological: anxious, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm.
NGN: The client is a 49-year-old male who reports flu like symptoms including fever
and chest congestion for four days. He came to the emergency department last night
when he was having more difficulty breathing he has a history of 1/2 pack a day cigarette
smoking for 20 years. He has no significant medical or surgical history.
The nurse should place the client in a _______________ position to promote
_____________. CORRECT ANSWER: Semi-Fowler , lung expansion.
NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO, sputum
culture, start a PIV, start oxygen 3L via nasal cannula, normal saline 150 ML per hour,
acetaminophen 350mg PO every six hours for temp greater than 101F, chest x-ray.
0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater than
94%.
(mark whether the statements by the new grad nurse indicate understanding or no
understanding of the use of facemask in the care of this client)
-I should clean the facemask once per shift.
-The client should take a 1 to 2 minute break from the facemask each hour.
-I should put gauze under the elastic straps over the ears.
-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation
greater than 94%.
-The mask should cover only the mouth and leave the nose open for expiration.
-I should place the mask first over the nose and then cover the mouth. CORRECT
ANSWER: -I should clean the facemask once per shift. (UNDERSTANDING)
-The client should take a 1 to 2 minute break from the facemask each hour. (NOT
UNDERSTANDING)
-I should put gauze under the elastic straps over the ears. (NOT UNDERSTANDING
????)
The nurse has completed the diet teaching of a client who is being discharged following
treatment of a leg wound. A high-protein diet is encouraged to promote wound healing.
Which lunch toys by the client indicates that the teaching was effective?
A) A peanut butter sandwich with soda and cookies.
B) Vegetable soup, crackers, and milk.
C) A tuna fish sandwich with chips and ice cream.
D) A salad with three kinds of lettuce and fruit. CORRECT ANSWER: C) A tuna fish
sandwich with chips and ice cream.
A client with foul-smelling drainage from an incision on the upper left arm is admitted
with a suspected MRSA. Which nursing intervention should the nurse include in the
plan of care? SATA.
A) Institute contact precautions for staff and visitors.
B) Use standard precautions and wear a mask.
C) Send wound drainage for culture and sensitivity.
D) Monitor the clients white blood cell count.
E) Explain the purpose of a low bacteria diet. CORRECT ANSWER: A) Institute
contact precautions for staff and visitors.
C) Send wound drainage for culture and sensitivity.
D) Monitor the clients white blood cell count.
An adult client who is admitted to the mental health unit for treatment of bipolar
disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment
finding is most important for the nurse to report to the healthcare provider?
A) Weight loss of 10 pounds in the past month.
B) Six hours of sleep in the past three days.
C) Blood alcohol level of 0.09%.
D) Serum lithium level of 1.6. CORRECT ANSWER: D) Serum lithium level of 1.6.
When conducting diet teaching for a client who is on a post operative full liquid diet,
which foods should the nurse encouraged the client to eat? SATA.
A) Clear beef broth.
B) Vanilla frozen yogurt.
C) Vegetable juice.
D) Creamy peanut butter.
E) Canned fruit cocktail. CORRECT ANSWER: A) Clear beef broth.
B) Vanilla frozen yogurt.
C) Vegetable juice.
,An infant born with esophageal atresia and tracheoesophageal fistula receives a
prescription for internal feedings after corrective surgery. To promote normal growth
and development of the infant, which action should the nurse include in the plan of
care? CORRECT ANSWER: Offer a pacifier for non-Nutritive sucking
The nurse is preparing a four year-old client with a serum bilirubin level of 19 for
discharge from the hospital. When teaching the parents about home photo therapy,
which instruction should the nurse include in the discharge teaching plan?
A) Cover with a receiving blanket.
B) Perform diaper changes under the light.
C) Feed the infant every four hours.
D) Reposition the infant every two hours. CORRECT ANSWER: D) Reposition the
infant every two hours.
When preparing to administer a prescribed medication to a homeless client at a
community psychiatric clinic. The client tells the nurse that the usual dosage taken is
different from the dose the nurse is giving. Which action should the nurse take?
A) Inform the client that he may refuse the medication and document whether or not
the client takes it.
B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at the next healthcare
team meeting. CORRECT ANSWER: B) Withhold the medication until the dosage can
be confirmed.
The charge nurse is making assignments for one practical nurse and three registered
nurses who are caring for neurologically compromised clients. Which client with which
change in status is best to assign to the PN?
A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10 to 7.
D) Myxedema, whose blood pressure change from 80/50 to 70/40. CORRECT
ANSWER: B) Viral meningitis whose temperature change from 101 S to 102F.
The nurse is caring for a client with pneumonia who now develops initial signs of septic
shock and multi organ failure. The healthcare provider prescribes a sepsis protocol.
Which intervention is most important for the nurse to include in the plan of care?
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level. CORRECT ANSWER: A) Maintain strict intake and
output.
,And adolescent client is admitted to the hospital because of writing a suicide note to a
teacher at school. On the second day of hospitalization, the nurse asked the client to
meet with the treatment team. After the team meeting, the client leaves in tears and
goes to their room. Which nursing intervention is best?
A) Let the client rest quietly in their room for a while.
B) Explore the clients goals and desire for treatment.
C) Ask the treatment team about the clients behavior.
D) Go to the clients room and ask what happened. CORRECT ANSWER: D) Go to the
clients room and ask what happened.
The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous
once a day for a client who weighs 154 pounds. The medication is available and 25,000
units per milliliter vial. How many milliliters should the nurse administer? (Enter
numerical value only. If rounding is required, round to the nearest 10th.) CORRECT
ANSWER: 0.6
NGN: The client is a 49-year-old male who reports flu like symptoms including fever
and chest congestion for four days. He came to the emergency department last night
when he was having more difficulty breathing he has a history of 1/2 pack a day cigarette
smoking for 20 years. He has no significant medical or surgical history.
Which two orders should the nurse complete first?
A) Sputum culture.
B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
D) Chest x-ray.
E) Acetominophen 350 mg PO every six hours for temperature control.
F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.
G) Start peripheral IV.
H) NPO. CORRECT ANSWER: B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
NGN: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start
a peripheral IV infusion, start oxygen 3 L per minute via nasal cannula, begin 0.9%
sodium chloride IV infusion at 150 mL per hour, acetaminophen 350 mg PO every six
hours for temperature.
To start the client on oxygen as ordered which items should the nurse collects from the
supply room? SATA
A) humidifier bottle.
B)Suction canister.
C)Sterile water.
D) Nasal cannula.
E) Flow meter.
F) Lambs wool.
G) Tape. CORRECT ANSWER: D) Nasal cannula.
E) Flow meter.
, NGN: states, I am feeling extremely anxious right now. The client has decreased breath
sounds in the left lower low. His mucus membranes are dry. He has a productive cough
with thick, yellow secretions. His capillary refill is four seconds. Vital signs, temperature
100.2. Heart rate 101 bpm, respiratory rate 28 breaths per minute, blood pressure
145/89, oxygen saturation 90% on room air.
(for each body system click to specify the assessment findings that indicates hypoxia)
Cardiovascular: heart rate 100 bpm, capillary refill for seconds, blood pressure 145/89.
Neurological: anxious, awake and alert, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm, productive
cough. CORRECT ANSWER: Cardiovascular: capillary refill for seconds, blood
pressure 145/89.
Neurological: anxious, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm.
NGN: The client is a 49-year-old male who reports flu like symptoms including fever
and chest congestion for four days. He came to the emergency department last night
when he was having more difficulty breathing he has a history of 1/2 pack a day cigarette
smoking for 20 years. He has no significant medical or surgical history.
The nurse should place the client in a _______________ position to promote
_____________. CORRECT ANSWER: Semi-Fowler , lung expansion.
NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO, sputum
culture, start a PIV, start oxygen 3L via nasal cannula, normal saline 150 ML per hour,
acetaminophen 350mg PO every six hours for temp greater than 101F, chest x-ray.
0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater than
94%.
(mark whether the statements by the new grad nurse indicate understanding or no
understanding of the use of facemask in the care of this client)
-I should clean the facemask once per shift.
-The client should take a 1 to 2 minute break from the facemask each hour.
-I should put gauze under the elastic straps over the ears.
-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation
greater than 94%.
-The mask should cover only the mouth and leave the nose open for expiration.
-I should place the mask first over the nose and then cover the mouth. CORRECT
ANSWER: -I should clean the facemask once per shift. (UNDERSTANDING)
-The client should take a 1 to 2 minute break from the facemask each hour. (NOT
UNDERSTANDING)
-I should put gauze under the elastic straps over the ears. (NOT UNDERSTANDING
????)
