Hesi PN Exit Exam 2025

1. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for eight hours, how many ml of full-strength feeding will the nurse need? (Enter numeric value only.) – 200 ml . 25 ml of full strength feeding mixed with 25ml of water provided 50ml of half strength. 25ml × 8 hours= 200ml 2. An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? - Apply an external condom catheter 3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement? - Reschedule administration of the antibiotic until after he completes his prayers 4. UAP using a hand sanitzers that is alcohol for 2 minutes - tell that hand sanitizer use is less > 2min 5. 5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The child weighs 44 pounds. How many mg of the medication should the nurse administer - Answer: 800 Rationale: First, convert the child's weight to kg: 44 pounds divided by 2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg 6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather than trickles from the vagina. The uterine fundus is firm and the client's vital signs are pulse 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take next? - Compare current vital signs with previous vital signs 7. A 6-year-old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye. Which action should the school nurse take? - Have the parent take the child for emergency help 8. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of "Altered thought processes, secondary to" what condition? - Postpartum psychosis 9. The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual cramps" for a 25-year-old female client. Which self-care activity should the nurse emphasize in the client's teaching plan? - Regular aerobic exercise. 10. Psych/Alcohol/Tylenol overdose antidote - Give Mucomyst 11. Medical Surgical/Laxative abuses - Patient -taking Milk of Magnesium 12. Spiritual/Documentation - Native American - Allow pt's family to stay in the room 13. Leadership- Interpreter informed consent - Pt should sign the consent 14. Geriatrics/Emergency Rib fractures fall - Pulmonary embolism 15. A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client's family? - Involve the client in usual at home activities 16. Upon assessment, the nurse discovers that a postpartum client has persistent red lochia. Which of the following does this assessment finding suggest to the nurse? - Coagulation disorders 17. The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is drained. What action should the nurse complete first? - Assess vital signs. 18. After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? - Clamp the tube 19. The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.; Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000. What should the nurse implement? - Determine if Client B has two units of packed cells available in the blood bank. 20. Triage question with a train wreck the psychiatric nurse is called to a train derailment that was likely caused by a terrorist bomb. In triaging those in need of immediate care, what is the priority ranking for these cases? (arrange these cases in order or priority with the top item requiring the most immediate care and the bottom item requiring the least priority care) - A mother and father have just arrived on the. A crying child being held by another passenger. A woman sitting on the ground with a blanket. A middle-aged man who is wandering around (arrange in order) = middle age woman bleeding- woman w/ blanket- child crying- mother and father. (Mine didn't have a middle age woman bleeding, instead it had an old man wandering and - correct order is: wandering old man, woman w/blanket, man holding baby, and mother & father) 21. The nurse in the emergency department is using the simple triage and rapid transport (START) system to assess victims of a hurricane. Which statement correctly describes a yellow disaster tag? - A yellow disaster tag means critical injuries and require immediate intervention. 22. What makes a baby frontal bulge or rises - crying 23. Which of the following is a nursing intervention for a 3-year-old client who is going in for surgery in 8 hours that has an order for fluid restriction? - Do not allow the child to drink fluids 24. The ear, where do u pull to give a ear drop - it a picture so look it up online (KNOW CHILD & ADULT) (pull the pinnae top side of ear; u can look at a picture to see exactly where pinnae is) (Mine had a picture of ear and put it on the lobule of the pinnae it is the ear lobe). The eye picture asked to find the macula or the fovea centralis (there are 2 prominent spots on the eye - choose the DARK spot to the left not the spot where the light is) 25. Know your serum levels? – K- 3.5-5.1, Na - 135-145, Ca 9-11, BUN - 10-20 26. When to use drug for motion sickness drug question - Take Zofran 4 hours before going on trip via sea. 27. Pt with DM - she states that she has to eat lunch rite after the gets her insulin to prevent going to hypoglycemia 28. Electrical burn pt - put him in a cardiac telemetry monitor 29. Which discharge instruction has the greatest priority for the mother of a 6-year- old who was diagnosed with Type 1 diabetes mellitus one week ago? - "Always carry a quick source of sugar 30. A nurse working on a mental health unit where a diagnosis of bulimia nervosa is being admitted. Which of the following symptoms would the nurse most likely NOT expect to find with this client? - severe over-or under-weight 31. The charge nurse is developing the nursing guidelines for a coronary care unit. Which references is likely to be the most useful in developing these guidelines? - The Scope of Standards of Practice from the American Nurses Association 32. Which assessment finding indicates a client's readiness to leave the nursing unit for a Bronchoscopy? - On-call sedation administered. 33. A nurse-manager is preparing an annual budget for the unit. Nursing salaries should be included in which component of the budget? - Operating budget 34. The nurse has not finished administering routine oral medication because on e client experienced chest pain and another rectal bleeding. It is now dinner time and two clients must be fed. The unlicensed assistive personnel (UAP) is filling water pitchers and the practical nurse (PN) is charting vital signs. Which change in assignments is best for the team leader to make? - UAP feed the two clients, PN finish oral medications and RN monitor clients with chest pain and rectal bleeding 35. What is manntiol drug used for? - To promote diuresis in prevention and treatment of oliguric phase of renal failure, ICP, IOP, edema in CHF. 36. The nurse is caring for a 42 year old male client who is excreting less sodium than he is consuming. If this condition continues, what complication can the nurse expect this client to exhibit? - Edema 37. A 40-year-old client with type 1 diabetes developed chronic kidney (CKD) disease 6 months ago. Because of secondary complications often associated with this illness the nurse plans to carefully assess for signs of what condition? - Anemia 38. A pt on a trachea/endotrach with gurgling sound - always pick suctioning 39. Know how the chest tube vac machine works - there is a picture of a chest tube vac machine. - this q is very easy just mark the spot on the tube for the amount of 125 ml of drainage 40. Child w/ hemophila - have parent pad the corners of the furniture due to bleeding. 41. You are preparing a plan of care for a client who is a Jehovah's Witness.The client has been told that surgery is necessary. With consideration to the client's religious preferences in development of the plan of care, you would document what? - The administration of blood and blood products is forbidden 42. A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely for what? - Drug toxicity 43. A 68-year-old male has been admitted to the hospital with abdominal pain, anemia and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. - The nurse should help him onto the bedpan/with the urinal 44. Nurse writes on the chart of Bob Miller that his nurse, Nurse Smith did not take great care of Mr. Miller. Nurse Jones has committed which of the following? - Libel 45. A client is prescribed Zolpidem (Ambien). Which of the following side effects should be monitored while the client is taking this medication? - Daytime drowsiness 46. Translator is working with the nurse who is giving discharge instructions to a non- English client. When the translator restates what the nurse is saying it appears that he is saying much more than what the nurse said. What action should the nurse take? - Ask the translator if there is a reason for the lengthiness of the translation 47. Who is at risk for rib fracture - Elderly pt. 48. Splint - Chest compression or chest splint after surgery - they used it for comfort 49. Metabolic syndrome - high cholesterol & - high cholesterol & high BP (cardiac strip) 50. Know how to prevent SIDS death - Instruct parents to have a firm mattress and avoid laying infant in prone position. 51. Hypertension Diet Teaching- presented with a list of menu choices, the best choice was - Baked pork chops, applesauce,etc 52. Teenager attempted suicide and during group session became upset and left group - Go to client room and ask what happened. 53. Client has rapid speech, flight of ideas, 3hrs of sleep - client experiencing high levels Depakote 54. New RN to Unit - best client to assign is client 4 days post MI 55. Incorrect Delegation - LVN/LPN to remove staples from abdominal wound 56. While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? - Withdraw the nasogastric tube 57. One week after client received above the knee amputation, client experiences phantom pain in left foot, what to do - Review causes and sensations of phantom pain 58. The nurse-manager of a perinatal units is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit? - A 35-year-old with lupus erythematosus 59. Decerebrate Positioning - Extension of the upper and lower extremity. 60. Four clients arrive at the labor and delivery nurses' station at the same time. Which pt should the nurse assess first? - A 38-week multigravida with biophysical profile score of 4 out of 8 61. Teenagers Teaching for Diabetic diet - Teenagers Teaching for Diabetic diet - Teach to look out for restaurant that have healthy food. 62. Pyelonephritis symptoms - elevates temperature 63. Leg cast Assessment - Compartment syndrome 64. Diagnosis of breast cancer - Needle aspiration or biopsy. 65. Risk Osteoarthritis - seen in long distance runner since high school client 66. Client skin integrity for client with chronic venous insufficiency - around the ankle with little pain. 67. IV Line - Flush line before and after compatible IV solution 68. Teaching - Carafate given before and after meal 69. Nurse given a change in drug orders via phone from physician for a client headed to radiology, place in order what steps the nurse should take first to last? - (Place in order) 1- read order back 2-enter verbal prescription 3- administer prn meds 4- prepare client for x-ray procedure 70. Heparin - Hematoma assessment 71. When the nurse auscultates the anterior chest just above the right nipple moderate, pitched breath sounds are heard that are equal on inspiration and expiration. Which statement best describes this finding? - Bronchovesicular breath sounds that are normal in that location 72. Priority pt - Ruptured spleen life threatening