3/17/25, 7:55 HESI with Rationale 12 366 rn exit Hesi Flashcards |
AM
HESI WITH RATIONALE 12 366 RN EXIT HESI EXAM QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS VERIFIED
Terms in this set (163)
The healthcare provider prescribes Answer
methylergonovine maleate for a C. Hypertension.
postpartum client with uterine atony.
What findings should indicate to Rationale
the nurse to Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can
withhold the next dose of the exaggerate primary hypertension. The nurse should withhold the
medication? medication if the client's blood pressure is elevated (C) and notify
the healthcare provider. (A, B, and D) are signs of uterine atony
A. Excessive lochia.
and are indications for the use of the medication.
B. Saturation of more than one
pad per hour.
C. Hypertension.
D. Difficulty locating the uterine
fundus.
The nurse has completed the diet Answer
teaching of a male client who is B. A tunafish sandwich with chips and ice cream.
being discharged following
treatment of a leg wound. A high Rationale
protein diet is encouraged to (B) contains the highest amount of protein. Four ounces of tuna contains 11 g of
promote protein, and ice cream 5 g of protein per cup. Chips are a fat with
wound healing. Which lunch choice virtually no protein value. (A) contains 4 grams of protein per
by the client indicates that the tablespoon. (C) contains only 1 gram of
teaching was effective? protein per 1 cup serving. (D) may have beef flavoring but it
consist mostly of vegetables and would therefore be low
A. A peanut butter sandwich with in protein.
soda and cookies.
B. A tunafish sandwich
with chips and ice cream.
C. A salad with three kinds of
lettuce and fruit.
D.Vegetable soup, crackers, and
milk.
The nurse discontinues a continuous Answer
IV C. The client states that his right calf is aching, and wants pain medication.
heparin infusion for a male client
on strict bed rest, and is now Rationale
preparing to administer the A calf ache severe enough for the client to request pain medication
client's first dose of in (C) should be reported to the healthcare provider immediately so
enoxaparin (Lovenox). Prior to that an adjustment in the anticoagulation therapy can be made.
giving this subcutaneous injection, Calf pain may be a sign of deep vein
1/46
,3/17/25, 7:55 HESI with Rationale 12 366 rn exit Hesi Flashcards |
AM
which assessment finding requires thrombosis indicative of ineffective anticoagulant heparin therapy.
additional intervention by the (A and B) are expected findings. Shaving with an electric razor is
nurse? recommended to reduce the possibility of bleeding (D) and does
not require intervention.
A. Current lab report indicates an
aPTT at
1.5 times the client's control.
B. Several bruised areas are
noted on the client's upper
extremities bilaterally.
C. The client states that his right calf
is aching, and wants pain
medication.
D. The spouse is assisting the client
who is
shaving with an electric razor.
While the nurse is providing Answer
morning care for a client with D. Assist the client to an upright position.
chronic obstructive
pulmonary disease (COPD), the Rationale
client becomes very dyspneic and The nurse should first assist the client to an upright position (D),
starts to panic. which allows the lungs to expand fully. After this, the nurse can
What action should the nurse implement (A, B, and C) as needed.
implement first?
A. Instruct the client to
perform diaphragmatic
breathing.
B. Use a calm voice to tell the
client to breathe slowly.
C. Administer two puffs of a
metered-dose inhaler.
D.Assist the client to an upright
position.
A female client's estranged Answer
husband arrives at the hospital B. Request a multidisciplinary care conference to discuss husband's demands.
and demands that his wife
have no other visitors. The client Rationale
becomes angry and insists that A multi-disciplinary care conference involves the healthcare team
the estranged to evaluate difficult situations that conflict with client safety and
husband be barred from visiting autonomy. During this
her. Which intervention should conference, the client's wishes regarding her health care
the nurse implement? decisions can be clarified to all team members. All other
options are not indicated.
A. Obtain a prescription to allow
client to dictate who can visit.
B. Request a multidisciplinary care
2/46
,3/17/25, 7:55 HESI with Rationale 12 366 rn exit Hesi Flashcards |
AM
conference to discuss husband's
demands.
C. Have the hospital's
medical-legal department
meet with the client.
D. Encourage the client to speak with
husband regarding his disruptive
behavior.
The nurse working in a critical Answer
care unit is assigned the care of A. Assess the level of consciousness and vital signs for both clients.
two clients, one with
pneumonia who is being Rationale
mechanically Assessing the level of consciousness and vital signs for both
ventilated and the other who had a clients (A) provides a quick measurement of priority need. Before
thoracotomy yesterday and is a complete assessment (B) is done on one client, the nurse
complaining of incisional pain. should at least do a quick assessment of the other client.
What should the nurse to first? Changing the dressing and observing the incision (C) may be indicated, but
only
after both clients are quickly assessed. Reviewing the plan of care
A. Assess the level of
and medications due for administration (D) should wait until the
consciousness and vital signs
nurse has evaluated both clients for any urgent clinical needs.
for both clients.
B. Complete a head to toe
assessment of the client with
pneumonia.
C. Change the surgical dressing to
observe the appearance of the
incision.
D. Review the plan of care and the
medications that are due for both
clients.
A woman at 24 weeks gestation Answer
who has fever, bodyaches, and C. Assign private room.
has been coughing for the last 5
days is sent to the hospital with Rationale
admission prescriptions for Novel H1N1 ("swine flu virus"), a new subtype of influenza A virus, is exhibited by
H1N1 fever, cough, sore throat, runny nose, body aches, headache, chills,
influenza. Which prescription has fatigue, diarrhea, and vomiting. According to the Center for Disease
the highest priority? Control, it is best to place a client requiring Contact or Droplet
Precautions in a single client room, so to protect
A. Obtain specimens for cultures. others, the client who is exhibiting signs of Novel H1N1 influenza
B. Vital signs q4 hours. should be assigned to a private room (C). (A, B, and D) do not
C. Assign private room. have the right the priority of (C).
D. Ringers lactate IV 125 mL/8 hours.
3/46
, 3/17/25, 7:55 HESI with Rationale 12 366 rn exit Hesi Flashcards |
AM
A client who received partial Answer
thickness B. Explain the procedure to the client.
(second degree) burns over the
anterior surfaces of both arms, Rationale
legs, and chest in a burning Before implementing any new procedure, an explanation of the
vehicle collision receives a procedure should be provided (B). Bringing large pieces of
prescription for daily dressing equipment into the client's room (A), such as a mechanical lift,
changes and therapeutic baths. may alarm the client if the procedure has not been explained.
The nurse determines The client should be medicated (C), but first explaining what is
that a hoist is required to move the involved in the procedure helps prepare the client for subsequent
immobile client from a stretcher into actions. Dressing bandages
the
provide protection for the wounds and help eliminate exposure
therapeutic bath. Which
to air, which can cause pain, so removal should be done
intervention should the nurse
immediately prior to submersion in the bath (D).
implement first?
A. Obtain the hoist from the supply
room.
B. Explain the procedure to the
client.
C. Medicate the client with an
analgesic.
D. Remove all bandages prior to
moving the client.
4/46
AM
HESI WITH RATIONALE 12 366 RN EXIT HESI EXAM QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS VERIFIED
Terms in this set (163)
The healthcare provider prescribes Answer
methylergonovine maleate for a C. Hypertension.
postpartum client with uterine atony.
What findings should indicate to Rationale
the nurse to Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can
withhold the next dose of the exaggerate primary hypertension. The nurse should withhold the
medication? medication if the client's blood pressure is elevated (C) and notify
the healthcare provider. (A, B, and D) are signs of uterine atony
A. Excessive lochia.
and are indications for the use of the medication.
B. Saturation of more than one
pad per hour.
C. Hypertension.
D. Difficulty locating the uterine
fundus.
The nurse has completed the diet Answer
teaching of a male client who is B. A tunafish sandwich with chips and ice cream.
being discharged following
treatment of a leg wound. A high Rationale
protein diet is encouraged to (B) contains the highest amount of protein. Four ounces of tuna contains 11 g of
promote protein, and ice cream 5 g of protein per cup. Chips are a fat with
wound healing. Which lunch choice virtually no protein value. (A) contains 4 grams of protein per
by the client indicates that the tablespoon. (C) contains only 1 gram of
teaching was effective? protein per 1 cup serving. (D) may have beef flavoring but it
consist mostly of vegetables and would therefore be low
A. A peanut butter sandwich with in protein.
soda and cookies.
B. A tunafish sandwich
with chips and ice cream.
C. A salad with three kinds of
lettuce and fruit.
D.Vegetable soup, crackers, and
milk.
The nurse discontinues a continuous Answer
IV C. The client states that his right calf is aching, and wants pain medication.
heparin infusion for a male client
on strict bed rest, and is now Rationale
preparing to administer the A calf ache severe enough for the client to request pain medication
client's first dose of in (C) should be reported to the healthcare provider immediately so
enoxaparin (Lovenox). Prior to that an adjustment in the anticoagulation therapy can be made.
giving this subcutaneous injection, Calf pain may be a sign of deep vein
1/46
,3/17/25, 7:55 HESI with Rationale 12 366 rn exit Hesi Flashcards |
AM
which assessment finding requires thrombosis indicative of ineffective anticoagulant heparin therapy.
additional intervention by the (A and B) are expected findings. Shaving with an electric razor is
nurse? recommended to reduce the possibility of bleeding (D) and does
not require intervention.
A. Current lab report indicates an
aPTT at
1.5 times the client's control.
B. Several bruised areas are
noted on the client's upper
extremities bilaterally.
C. The client states that his right calf
is aching, and wants pain
medication.
D. The spouse is assisting the client
who is
shaving with an electric razor.
While the nurse is providing Answer
morning care for a client with D. Assist the client to an upright position.
chronic obstructive
pulmonary disease (COPD), the Rationale
client becomes very dyspneic and The nurse should first assist the client to an upright position (D),
starts to panic. which allows the lungs to expand fully. After this, the nurse can
What action should the nurse implement (A, B, and C) as needed.
implement first?
A. Instruct the client to
perform diaphragmatic
breathing.
B. Use a calm voice to tell the
client to breathe slowly.
C. Administer two puffs of a
metered-dose inhaler.
D.Assist the client to an upright
position.
A female client's estranged Answer
husband arrives at the hospital B. Request a multidisciplinary care conference to discuss husband's demands.
and demands that his wife
have no other visitors. The client Rationale
becomes angry and insists that A multi-disciplinary care conference involves the healthcare team
the estranged to evaluate difficult situations that conflict with client safety and
husband be barred from visiting autonomy. During this
her. Which intervention should conference, the client's wishes regarding her health care
the nurse implement? decisions can be clarified to all team members. All other
options are not indicated.
A. Obtain a prescription to allow
client to dictate who can visit.
B. Request a multidisciplinary care
2/46
,3/17/25, 7:55 HESI with Rationale 12 366 rn exit Hesi Flashcards |
AM
conference to discuss husband's
demands.
C. Have the hospital's
medical-legal department
meet with the client.
D. Encourage the client to speak with
husband regarding his disruptive
behavior.
The nurse working in a critical Answer
care unit is assigned the care of A. Assess the level of consciousness and vital signs for both clients.
two clients, one with
pneumonia who is being Rationale
mechanically Assessing the level of consciousness and vital signs for both
ventilated and the other who had a clients (A) provides a quick measurement of priority need. Before
thoracotomy yesterday and is a complete assessment (B) is done on one client, the nurse
complaining of incisional pain. should at least do a quick assessment of the other client.
What should the nurse to first? Changing the dressing and observing the incision (C) may be indicated, but
only
after both clients are quickly assessed. Reviewing the plan of care
A. Assess the level of
and medications due for administration (D) should wait until the
consciousness and vital signs
nurse has evaluated both clients for any urgent clinical needs.
for both clients.
B. Complete a head to toe
assessment of the client with
pneumonia.
C. Change the surgical dressing to
observe the appearance of the
incision.
D. Review the plan of care and the
medications that are due for both
clients.
A woman at 24 weeks gestation Answer
who has fever, bodyaches, and C. Assign private room.
has been coughing for the last 5
days is sent to the hospital with Rationale
admission prescriptions for Novel H1N1 ("swine flu virus"), a new subtype of influenza A virus, is exhibited by
H1N1 fever, cough, sore throat, runny nose, body aches, headache, chills,
influenza. Which prescription has fatigue, diarrhea, and vomiting. According to the Center for Disease
the highest priority? Control, it is best to place a client requiring Contact or Droplet
Precautions in a single client room, so to protect
A. Obtain specimens for cultures. others, the client who is exhibiting signs of Novel H1N1 influenza
B. Vital signs q4 hours. should be assigned to a private room (C). (A, B, and D) do not
C. Assign private room. have the right the priority of (C).
D. Ringers lactate IV 125 mL/8 hours.
3/46
, 3/17/25, 7:55 HESI with Rationale 12 366 rn exit Hesi Flashcards |
AM
A client who received partial Answer
thickness B. Explain the procedure to the client.
(second degree) burns over the
anterior surfaces of both arms, Rationale
legs, and chest in a burning Before implementing any new procedure, an explanation of the
vehicle collision receives a procedure should be provided (B). Bringing large pieces of
prescription for daily dressing equipment into the client's room (A), such as a mechanical lift,
changes and therapeutic baths. may alarm the client if the procedure has not been explained.
The nurse determines The client should be medicated (C), but first explaining what is
that a hoist is required to move the involved in the procedure helps prepare the client for subsequent
immobile client from a stretcher into actions. Dressing bandages
the
provide protection for the wounds and help eliminate exposure
therapeutic bath. Which
to air, which can cause pain, so removal should be done
intervention should the nurse
immediately prior to submersion in the bath (D).
implement first?
A. Obtain the hoist from the supply
room.
B. Explain the procedure to the
client.
C. Medicate the client with an
analgesic.
D. Remove all bandages prior to
moving the client.
4/46
