2025 HESI RN EXIT MIDTERM EXAM V1 GRADED A+

1. The nurse is aware that intimate partner violence (IPV) screening should occur with which situation? A. As soon as the clinician suspects a problem. B. As a routine part of each health care encounter C. Once the clinician confirms a history of abuse D. Only when the client presents with an unexpected injury. 2. A client is admitted with diagnosis of Wernicke’s syndrome. Which assessment finding should the nurse….? A. Confusion B. Right lower abdominal pain C. Peripheral neuropathy D. Depression 3. A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? A. Measure urine output B. Assess body temperature. C. Monitor skin elasticity. D. Observe the aspiration site. 4. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He was treated and released but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention. A. Instruct visitors to gown and wash hands. B. Maintain contact transmission precaution. C. Review WBC count daily. D. Collect serial stool specimens for culture. 5. After an elderly female client receives treatment for drug toxicity, the healthcare provider prescribes a 24 hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3 mg/dl (22.9 micromol/L). What action should the nurse implement? A. Notify HCP of the results. B. Assess the client for signs of hypokalemia. C. Evaluate client’s serum BUN level. D. Initiate the urine collection as prescribed. 6. Prior to insertion of an indwelling urinary catheter, what client information is most important for the nurse to obtain? A. Color, clarity, and odor of urine. B. Client allergies to antiseptic solution. C. Previous history of UTI D. Client’s ability to increase fluid intake. 7. An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic pain. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure, and chest movement on the right side of the thorax. Which procedure should the nurse prepare for first: A. Insertion of a left- sided chest tube B. Setup of PCA C. Retraction of the nasogastric tube D. Placement of endotracheal tube 8. The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials? 1. Verify the drug and dose with the label on the vial. 2. Inject the volume of air to be aspirated from each vial. 3. Aspirate from vial A 4. Aspirate from vial B 9. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement? A. Assign UAP to take vitals every hour. B. Advise the client that anticoagulant therapy may be needed. C. Call the lab to obtain a stat APTT and prothrombin time. D. Document the extent of the bruising in the medical record. 10. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A. Begin to show signs of improvement in affect. B. Lacks interest in the activities of family and friends C. Expresses feelings of sadness and loneliness. D. Neglects personal hygiene and has no appetite. 11. A 3 year-old boy is brought to the emergency department after the mother found the child in the backyard holding a piece of a toy in his hand and in respiratory distress. The child is dusky with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse implement? A. Obtain a pulse oximetry reading and arterial blood gases. B. Determine if the child ingested a toxic substance and if vomiting occurred. C. Request a stat chest x-ray and prepare medications for asthmatic episodes. D. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver. 12. While moving stables from the client's postoperative wound site, the nurse observes that the client's eyes closed and his face and hands are clenched. The client states, "I just hate having staples removed." Acknowledge the client’s anxiety, which action should the nurse implement? A. Attempt to distract the client with general conservation. B. Reassure the client that this is a simple nursing procedure. 35 mL C. Explain the procedure in detail while removing stables. D. Encourage the client to continue to verbalize anxiety. 13. HCP prescribes cephalexin 125mg/5ml oral suspension. Client weighs 77 lbs. The recommended safe dose 25 mg/kg/24hrs 14. What is the primary purpose for initiating nursing interventions that promote good nutrition, rest, exercise, and stress reduction for a client diagnosed with HIV? A. B. Promote a feeling of general well-being C. Increase ability to carry out activities of daily living D. Prevent spread of infection to others 15. A client with chronic obstructive lung disease who is receiving oxygen at 1.5 liters per minute by nasal cannula is currently short of breath. What should the nurse do? A. Instruct the client in pursed lip breathing B. Increase oxygen to three liters/ per minute C. Ask client to take short rapid breaths D. Have the client breathe into a paper bag 16. The nurse is caring for a child who takes methylphenidate extended release for the treatment of attention deficit hyperactivity disorder (ADHD). Which assessment finding is an expected side effect of this medication? A. Flat affect B. Decrease Focus C. Weight loss of 5lbs in 1 month D. Muscle weakness Improve function of the immune system. 17. A client with purulent discharge from a venous ulcer that has been unsuccessfully treated with intravenous vancomycin has just been admitted with a possible vancomycin resistant staph infection. Which nursing interventions should the nurse include in the plan of care? A. Explain purpose of low bacteria diet B. Monitor clients WBC’s C. Institute contact precautions for staff and visitors D. Use standard precautions and wear a mask E. Send wound drainage for culture and sensitivity 18. Which client should the charge nurse on the oncology unit assign to an RN rather than a PN? A. A middle aged male client who has just undergone an excisional biopsy and has been told that his tumor appears to be benign. B. An adult client in remission after a series of chemotherapy treatments who is receiving intramuscular iron injections for anemia C. A young adult experiencing fatigue while undergoing a series of external beam radiation treatments for stage 1 cancer D. An elderly female client with cancer whose children are trying to decide whether to change the palliative care measures. 19. The nurse is assessing a client who is receiving enteral feedings. Which clinical data indicate the client may not be tolerating the tube feedings. A. Nausea and vomiting B. Abdominal tympany C. Absent bowel sounds D. Flatulence E. Abdominal cramping 20. A female client is admitted for the diabetic crisis resulting from inadequate dietary practices. After stabilization the nurse talks to the client about her prescribed diet. What client characteristics are most important ? A. Knows that insulin must be given 30 minutes before eating B. B. Demonstrates a willingness to adhere to the diet consistently. C. Frequently eat fruits and vegetables at meals and between meals D. Has someone available who can prepare and oversee the diet 21. The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention? A. A 12 year old reporting neck, arm, and lower back discomfort B. An 8 year old with a full leg air splint for a possible broken tibia C. An 11 year old with a headache, nausea, and projectile vomiting D. An 6 year old with multiple superficial lacerations of all extremities. 22. An 18 year old female client is seen at the health department for treatment of condylomata (perineal warts) caused by HPV. Which intervention should the nurse implement? A. Inform the client that wants do not return following cryotherapy B. Tell the client the vaccine for HPV is not indicated C. Reinforce the importance of annual Pap Smear D. Recommend the use of latex condoms to prevent HPV transmission 23. The nurse is working on an infectious disease unit. Which client should be assigned to a room, to use a particulate respirator mask and requiring staff to use standard precautions? A. Twin siblings admitted with scarlet fever that is complicated with pneumonia B. A client with a positive Mantoux and sputum cultures results positive for AFB C. A female adolescent admitted with multiple genital herpes simplex 1 lesions D. An older client with scabies who is admitted from an extended care facility 24. A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instruction is most important for the nurse to include in the teaching plan? A. Teach tracheal suctioning techniques B. Explain how to use communication tools C. Demonstrate how to clean tracheostomy site D. Encourage self-care and independence. 25. While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them at the nurse A. State it is unacceptable to undress during the interview B. Ignore the clients inappropriate behavior C. Change to less anxiety promoting questions D. Leave the clients room so she can act out her anxiety 26. A female client with dementia who needs assistance with meals and activities of daily living screams at the staff and threatens to hit those who come near her. Which intervention should the nurse include in the care plan? A. Risk for self directed violence B. Risk for acute confusion C. Impaired verbal communication D. Caregiver role strain 27. A female client with a history of heart failure arrives at the clinic after what she describes as a very…… (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner…… A) Reteach medication regimen. B) Administer the prescribed diuretic. c) Give a potassium supplement. D) Auscultate lung and heart sounds 28. When entering a client’s room to administer an 0900 iv antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor, Which action should the nurse implement? A) Ignore the behavior and hang the iv antibiotic. B) Complete an unusual occurrence report C) Leave the room and close the door quietly. D) Tell the client to stop the inappropriate behavior. 29. The healthcare provider prescribes the antibiotic cefdinir 300mg PO every 12 hrs for a client with a postoperative wound infection. Which foods should the nurse encourage…? A) Green leafy vegetables B) Avocados and cheese C) Yogurt or buttermilk d) Fresh fruits. 30) A client is receiving ophthalmic drops preoperatively for cataract extraction and …. Healthcare providers have prescribed all these medications. Which information a nurse will give to this client? (Select all that apply). A) One of the medications is used to anesthetize the corneal surface. B) These medications assist in obstructing a client's vision during the surgery. C) The iris must be paralyzed during surgery to prevent it from reacting to light. D) A medication is used to induce sleep during the procedure. E) Pupillary dilation is necessary to access the eye chamber for lens removal. 31) The nurse is managing 4 clients in the intensive care units who are mechanically ventilated. After performing a quick visual assessment, the nurse…………….. A) Restrained and restless with a low volume alarm sounding. B) High pressure alarm sounds when a client is coughing. C) An audible voice when a client is trying to communicate. D) Diminished breath sounds in the right posterior base. 32) Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse ………. Prasugrel, a platelet inhibitor, to the client. To monitor for ………….. A) Measure body temperature. B) Assess skin turgor C) Check for pedal edema. D) Observe the color of urine. 33) A client with hyperthyroidism is admitted to the postoperative unit after a successful thyroidectomy. Which of the client’s serum laboratory values requires intervention by the nurse? A) T3 – uptake at 50% B) Thyroxine 12 mcg/dl (154 nmol/L) C) Total calcium 5.0 mg/dL (1.25 mmol/L) D) Glucose 150 mg/dL (8.32 mmol/L) 34) A postpartal client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide the client? D. place warm packs on both of the breast. 35) The mother of an adolescent female tells the clinic nurse that every meal her daughter goes to the bathroom, locks the door and vomits, which…….????? A) Current height and weight B) Skin of palms of the hand C) Condition of tooth enamel D) Length of the last menses. 36) Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medications should be held until a later time? A) The mucosal barrier, sucralfate, for a client diagnosed with peptic ulcer disease. B) The antifungal nystatin suspension, for a client who has just brushed his teeth. C) The antiplatelet agent aspirin, for a client who is scheduled to be discharged within the hour. D) The loop-diuretic furosemide, for a client with a serum potassium. 37) While changing a client’s postoperative dressing, the nurse observes purulent wound drainage at the site. Before reporting this finding to the healthcare provider, the nurse……. A) Platelet count B) Neutrophil count C) Serum sodium level D) Hematocrit. 38) A female client receives a prescription for alendronate sodium .. osteoporosis. Which instruction should the nurse include in the client’s teaching plan? A) Eat within 30 minutes of taking the medication B) Consume a light snack with the medication. C) Ingest an antacid 30 minutes prior to taking the tablet D) Take on an empty stomach with a full glass of water. 39) The nurse has determined that a client with no pernicious anemia has developed g…….. this problem? A) Pain when eating B) Nausea C) Altered taste sensation D) Fatigue 40. Based on the information provided in this client’s chart medical record during labor. Which should the nurse implement B.) Apply oxygen via face mask. 41. The nurse working in a critical care unit is assigned two clients being mechanically ventilated and the other who had a thoracotomy… -asses the level of consciousness and vital signs 42. Which instruction should the nurse provide to a client who is preparing to have cystoscopy -report any painful urination, blood in urine, or fever 43. The nurse implements a secondary prevention program for STI in a local health center -more than 50% of at risk clients were diagnosed early 44. An adult client is admitted to psychiatric Unit -phobia 45. Prior to surgery, written consent must be obtained. Which is the nurse’s legal responsibility…. -determine that the surgical consent form has been signed 46. The nurse is assigned to a care for a client diagnosed with psoriasis….? -shaking the client’s hand during an introduction 47. The nurse is preparing an adult with Addison’s disease for self-management…? -events requiring steroid dose adjustments 48. What is the priority nursing action when initiating morphine therapy via an intravenously…? -initiate the dosage lockout mechanism on the PCA pump 49. A nurse who took drugs from the unit for personal use was temporarily released from duty….? -allow the impaired nurse to return to work and monitor med admin 50. While taking vital signs, a critically ill male grabs the nurse’s hand and ask the nurse not to leave…..? -pull up a chair and sit beside the client’s bed 51. Which assessment finding of a postmenopausal woman…..? -cold sensitivity 52. The nurse is taking the blood pressure measurement of client with Parkinson’s (SATA) -flat affect, frequent syncope, blurred vision 53. A client is admitted to the intensive care unit with diabetes insipidus due to pituitary gland tumor…..? -Hypokalemia 54. In evaluating a client at 29 weeks gestation, which finding should the nurse report to the HCP immediately? a. Urinary frequency b. Whitish, odorless, mucoid vaginal discharge c. Temperature at 100 degrees F d. Edema of ankles, face and hands. 55. A client with multiple sclerosis is receiving baclofen 15 mg orally three times a day… ...... ?*4.5 56. The nurse is assisting the HCP with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created . Which nursing intervention should the nurse implement for client safety? a. Assess the discomfort when procedure is completed C. stay indoors when grass is being cut D. avoid sudden changes in temperature E. close car windows and use air conditioner b. Instruct the client to keep hands under the sterile field c. Verify that the client has given informed consent d. Pour cleaning solution onto the sterile cloth field. 57. The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers of asmthatic attacks, which instruction should the nurse provide the mother? A. decrease the raw sugars in her diet B. keep away from pets with long hair 58. When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include ….? a. Assess bilateral breath sounds b. Review client’s daily medications c. Initiate neurological monitoring every 2 hours. d. Palpate suprapubic region for urinary retention. 59. A client with a history of gouty arthritis is scheduled for a right total knee arthopathy. Which lab test result is most important for the nurse to report to the surgeon prior to th schedules surgery? a. Potassium level of 4 mEq/L (4mmol/L) b. Blood glucose of 90 mg/dL (5mmol/L) c. Serum creatinine of 5 mg/dL ( 442micromol/L) d. Hemoglobin level of 13 g/dL 60. The charge nurse is making assignments for one practical nurse (PN) and three registered nurses who are caring for neurologically compromised clients. Which client with which change of status is best to assign to the PN? a. Viral meningitis whose temperature changed from 101.0 to 102.0 F b. Myxedema coma whose blood pressure changed from 80/50 mmHg to 70/40 mm/Hg c. Diabetic ketoacidosis whose glasgow coma scale score changed from 10 to 7 d. Subdural hematoma whose blood pressure changed from 150/80 to 170.60 mmHg. 61. A client with possible acute kidney injury is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription what intervention should the nurse implement? a. Obtain vital signs and breath sounds b. Instruct the client to empty the bladder c. No specific nursing action is required d. Collect a clean catch urine specimen. 62. An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital with diabetic ketoacidosis. Which intervention is the most likely cause ….? a. Incorrectly administered too much insulin b. Skipped eating lunch c. Ate an extra peanut butter sandwich before gym class d. Had a cold and ear infection for the past 2 days. 63. The nurse notes that a client with depression has been more withdrawn and non- communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this ….? a. Schedule a daily conference with social worker b. Engage the client in non-threatening conversations c. Encourage the client to participate in group activities d. Encourage the clients family to visit more often. 64. The school nurse is called to the soccer field because a child has nose bleed. In which position should the nurse place the child? a. Supine with the legs raised b. Side lying with the head slightly elevated c. Sitting up and leaning forward d. Standing with the head leaning backwards 65. A client who is newly diagnosed with type 2 diabetes mellitus recieved a prescription formetformin 500 mg PO twice daily. What information should the nurse include in this clients teaching plan? a. Recognize signs and symptoms of hypoglycemia b. Use sliding scale insulin for fingerstick glucose elevations c. Report persistent polyuria to the HCP d. Take an additional dose for signs of hyperglycemia e. Take metformin with the morning and evening meal 66. An unlicensed assistive personnel is assigned to provide personal care for a client whose prescribed activity is bed rest with bedside commode use. The UAP reports to the nurse that the client? a. Advise the client to maintain bedrest so that the safety can be ensured. b. Determine the client's level of mobility and need for the assistance c. Assign another UAP to care for the client d. Instruct the UAP that all clients deserve equal care. 67. An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce the symptoms. In responding to the client, the nurse recognizes what.. B. Destruction of joint cartilage. 68. A client in the emergency center demonstrates rapid speech, flight of ideas and reports sleeping only three hours during the past 48 hours. Based on these findings, it is most important for the nurse to review the laboratory result for which medication? C. Fluoxetine 69. A 3 yo boy was successfully toilet trained prior to his admission to the hospital for ... are very concerned that the child has regressed in his toileting . What information should the nurse provide to the parents? A. Children usually resume their toileting behaviors when they leave the hospital. 70. Which intervention should the nurse implement when beginning a physical assessment of a 6 mo infant? A. Allow the child to remain sitting in the caretaker’s lap. 71. A male client with suspected lung cancer tells the nurse that he does not want to have a scheduled biopsy performed and states “they already found the cancer when I had my chest xray.” Which action should the nurse implement? C. Instruct the client that biopsy results are important to determine the best treatment. 72. An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period ... B. Teach clients to use an incentive spirometer every 2 courses while awake. E. Remove urinary catheter as soon as possible and encourage voiding. 73. The nurse applies a blood pressure cuff around the clients left thigh. To measure the client’s blood pressure where does the stethoscope need to be placed?