CURRENT HESI A2 EXIT EXAM V2 160
QUESTIONS & ANSWERS LATEST NEWLY
UPDATE 2025
The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which
nursing intervention is appropriate for this child?
A) Make certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort
D) Release the traction for 15-20 minutes every 6 hours PRN.
The nurse is reassigned to work at the Poison Control Center telephone hotline. In
which of these cases of childhood poisoning would the nurse suggest that parents have the
child drink orange juice?
A) An 18 month-old who ate an undetermined amount of crystal drain cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of
diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
, Which of these is an example of a variation in the newborn resulting from the
presence of maternal hormones?
A) Engorgement of the breasts
B) Mongolian spots
C) Edema of the scrotum
D) Lanugo
A 2 month-old child has had a cleft lip repair. The selection of which restraint would
require no further action by the charge nurse?
A) Elbow
B) Mummy
C) Jacket
D) Clove hitch
A client treated for depression tells the nurse at the mental health clinic that he
recently purchased a handgun because he is thinking about suicide. The first nursing
action should be to
A) Notify the health care provider immediately
B) Suggest in-patient psychiatric care
C) Respect the client's confidential disclosure
D) Phone the family to warn them of the risk
A client has just been admitted with portal hypertension. Which nursing diagnosis
would be a priority in planning care?
A) Altered nutrition: less than body requirements
B) Potential complication hemorrhage
C) Ineffective individual coping
D) Fluid volume excess
, While planning care for a 2 year-old hospitalized child, which situation would the
nurse expect to most likely affect the behavior?
A) Strange bed and surroundings
B) Separation from parents
C) Presence of other toddlers
, D) Unfamiliar toys and games
Which of the following should the nurse teach the client to avoid when taking
chlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramine
C) Foods fermented with yeast
D) Canned citrus fruit drinks
The initial response by the nurse to a delusional client who refuses to eat because ofa
belief that the food is poisoned is
A) "You think that someone wants to poison you?"
B) "Why do you think the food is poisoned?"
C) "These feelings are a symptom of your illness."
D) "You’re safe here. I won’t let anyone poison you."
The nurse is caring for a client with cirrhosis of the liver with ascites. When
instructing nursing assistants in the care of the client, the nurse should emphasize that
A) The client should remain on bed rest in a semi-Fowler's position
B) The client should alternate ambulation with bed rest with legs elevated
C) The client may ambulate and sit in chair as tolerated
D) The client may ambulate as tolerated and remain in semi-Fowler position in bed
The nurse is performing physical assessments on adolescents. When would the nurse
anticipate that females experience growth spurts?
A) About 2 years earlier than males
QUESTIONS & ANSWERS LATEST NEWLY
UPDATE 2025
The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which
nursing intervention is appropriate for this child?
A) Make certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort
D) Release the traction for 15-20 minutes every 6 hours PRN.
The nurse is reassigned to work at the Poison Control Center telephone hotline. In
which of these cases of childhood poisoning would the nurse suggest that parents have the
child drink orange juice?
A) An 18 month-old who ate an undetermined amount of crystal drain cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of
diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
, Which of these is an example of a variation in the newborn resulting from the
presence of maternal hormones?
A) Engorgement of the breasts
B) Mongolian spots
C) Edema of the scrotum
D) Lanugo
A 2 month-old child has had a cleft lip repair. The selection of which restraint would
require no further action by the charge nurse?
A) Elbow
B) Mummy
C) Jacket
D) Clove hitch
A client treated for depression tells the nurse at the mental health clinic that he
recently purchased a handgun because he is thinking about suicide. The first nursing
action should be to
A) Notify the health care provider immediately
B) Suggest in-patient psychiatric care
C) Respect the client's confidential disclosure
D) Phone the family to warn them of the risk
A client has just been admitted with portal hypertension. Which nursing diagnosis
would be a priority in planning care?
A) Altered nutrition: less than body requirements
B) Potential complication hemorrhage
C) Ineffective individual coping
D) Fluid volume excess
, While planning care for a 2 year-old hospitalized child, which situation would the
nurse expect to most likely affect the behavior?
A) Strange bed and surroundings
B) Separation from parents
C) Presence of other toddlers
, D) Unfamiliar toys and games
Which of the following should the nurse teach the client to avoid when taking
chlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramine
C) Foods fermented with yeast
D) Canned citrus fruit drinks
The initial response by the nurse to a delusional client who refuses to eat because ofa
belief that the food is poisoned is
A) "You think that someone wants to poison you?"
B) "Why do you think the food is poisoned?"
C) "These feelings are a symptom of your illness."
D) "You’re safe here. I won’t let anyone poison you."
The nurse is caring for a client with cirrhosis of the liver with ascites. When
instructing nursing assistants in the care of the client, the nurse should emphasize that
A) The client should remain on bed rest in a semi-Fowler's position
B) The client should alternate ambulation with bed rest with legs elevated
C) The client may ambulate and sit in chair as tolerated
D) The client may ambulate as tolerated and remain in semi-Fowler position in bed
The nurse is performing physical assessments on adolescents. When would the nurse
anticipate that females experience growth spurts?
A) About 2 years earlier than males
