HESI ADN EXIT HESI Simplified Exam Questions
And Answers Verified 100% Correct
When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which
approach should the nurse use?
• Explain that the client may be placed in five positions
A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a
series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely
experience a Bell’s palsy rather than a stroke?
• Inability to close the affected eye, raise brow, or smile
The nurse is teaching a client how to perform colostomy irrigations. When observing the client’s return
demonstration, which action indicated that the client understood the teaching?
• Keeps the irrigating container less than 18 inches above the stoma
104. The nurse should teach the client to observe which precaution while taking dronedarone?
• Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include
the client’s risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the
nurse that ICP has increased?
Confusion and papilledema
The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC).
Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?
• Confirm the necessity for continued use of the CVC.
During an annual physical examination, an older woman’s fasting blood sugar (FBS) is determined to be 140 mg/dl
or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that
the client has diabetes mellitus (DM)?
• Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. Best action?
• Determine if she can ask for support from family, friend, or the baby’s father.
. A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal
saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?
• Stop the normal saline infusion.
. An elderly female is admitted because of a change in her level of sensorium.During the evening shift, the client
attempts to get out bed and falls, breaking her left hip. Buck’s skin traction is applied to the left leg while waiting for
surgery. Which intervention is most important for the nurse to include in this client’s plan care?
• Ensure proper alignment of the leg in traction.
11. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed
during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should
the nurse take in response to this finding?
,• Document the ongoing wound healing.
12.At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, “I
just know I can’t handle all the pain.” What is the priority nursing diagnosis for this client?
• Anxiety
, The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the
membranes during labor. What intervention should the nurse implement immediately?
• Elevate the presenting part off the cord.
A client had a right hip replacement 3 day ago is pale w/ diminished breath sound over the left lower lung fields,
temperature of 100.2 F, oxygen saturation rate of 90%. Recommendation for HCP?
• Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg
PO twice daily. What information should the nurse include in this client’s teaching plan?
Recognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
The nurse is developing an educational program for older clients who are being discharged with new
antihypertensive medications. The nurse should ensure that the educational materials include which characteristics?
Select all that apply
• Contains a list with definitions of unfamiliar terms
• Uses common words with few Syllables
• Uses pictures to help illustrate complex ideas
An older male resident of LTC facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the
procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he
attempted to remove the sandbag from his femoral artery multiple times during the night. Best actions to take?
• Notify the healthcare provider of the client’s change in mental status.
• Include q2 hour’s reorientation in the client’s plan of care.
An older male comes to the clinic with a family member. When the nurse attempts to take the client’s health history,
he does not respond to questions in a clear manner. Which action should the nurse implement first?
• Assess the surroundings for noise and distractions.
The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4
hours. Based on this assessment, what should the nurse anticipate that client will need?
• Large amounts of fluid and electrolyte replacement.
121. Which intervention should the nurse include in the plan of care for a child with tetanus?
• Minimize the amount of stimuli in the room
122. Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic
overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client’s room. Best intervention?
• Remove cigarettes for the client’s room
123. A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What
information should the nurse provide? (Select all that apply.)
• A client must be willing to accept palliative care, not curative care.
• The healthcare provider must project that the client has 6 months or less to live.
124. A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse
include in this client’s teaching plan?
• Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
, 125. A nurse with 10 years experience working in the emergency room is reassigned to he perinatal unit to work an
8 hour shift. Which client is best to assign to this nurse?
• A mother with an infected episiotomy
126. An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic
with jugular vein distention. Which prescription should the nurse administer first?
• Digoxin.
127. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed
assistive personnel (UAP). Which task should the charge nurse assign to the RN?
• Supervise a newly hired graduate nurse during an admission assessment.
128. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the
distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action
should the nurse take?
• Ask the client what he is thinking about at his time.
129. After several hours of non-productive coughing, a client presents to the emergency room C/O of chest
tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and
diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement
bilaterally. Which actions should the nurse implement? (SATA)
Administer PRN nebulizer Obtain 12 lead Monitor continuous oxygen
treatment. electrocardiogram. saturation.
130. The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is
exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?
• Administer a prescribed analgesia for pain.
131. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes
methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about
caring for their child?
• Use sunblock or protective clothing when outdoors.
132. Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy.
Which actions should the nurse implement? (Select all that apply) Notify the food services department of the allergy.
Enter the allergy information in the client’s record. Add egg allergy to the client’s allergy arm band.
133.The rapid response team’s detects return of spontaneous circulation (ROSC) after 2 min of continuous chest
compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a
successful oral, intubation. What action should the nurse implement?
• Perform bilateral chest auscultation.
134. After administering an antipyretic medication. Which intervention should the nurse implement?
•Describe Encouraging radioactive liberal iodine fluid intakeas a tasteless, colorless medication administered by the
healthcare provider
135. A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be
included in preparing this client for this treatment?
And Answers Verified 100% Correct
When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which
approach should the nurse use?
• Explain that the client may be placed in five positions
A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a
series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely
experience a Bell’s palsy rather than a stroke?
• Inability to close the affected eye, raise brow, or smile
The nurse is teaching a client how to perform colostomy irrigations. When observing the client’s return
demonstration, which action indicated that the client understood the teaching?
• Keeps the irrigating container less than 18 inches above the stoma
104. The nurse should teach the client to observe which precaution while taking dronedarone?
• Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include
the client’s risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the
nurse that ICP has increased?
Confusion and papilledema
The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC).
Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?
• Confirm the necessity for continued use of the CVC.
During an annual physical examination, an older woman’s fasting blood sugar (FBS) is determined to be 140 mg/dl
or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that
the client has diabetes mellitus (DM)?
• Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. Best action?
• Determine if she can ask for support from family, friend, or the baby’s father.
. A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal
saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?
• Stop the normal saline infusion.
. An elderly female is admitted because of a change in her level of sensorium.During the evening shift, the client
attempts to get out bed and falls, breaking her left hip. Buck’s skin traction is applied to the left leg while waiting for
surgery. Which intervention is most important for the nurse to include in this client’s plan care?
• Ensure proper alignment of the leg in traction.
11. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed
during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should
the nurse take in response to this finding?
,• Document the ongoing wound healing.
12.At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, “I
just know I can’t handle all the pain.” What is the priority nursing diagnosis for this client?
• Anxiety
, The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the
membranes during labor. What intervention should the nurse implement immediately?
• Elevate the presenting part off the cord.
A client had a right hip replacement 3 day ago is pale w/ diminished breath sound over the left lower lung fields,
temperature of 100.2 F, oxygen saturation rate of 90%. Recommendation for HCP?
• Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg
PO twice daily. What information should the nurse include in this client’s teaching plan?
Recognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
The nurse is developing an educational program for older clients who are being discharged with new
antihypertensive medications. The nurse should ensure that the educational materials include which characteristics?
Select all that apply
• Contains a list with definitions of unfamiliar terms
• Uses common words with few Syllables
• Uses pictures to help illustrate complex ideas
An older male resident of LTC facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the
procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he
attempted to remove the sandbag from his femoral artery multiple times during the night. Best actions to take?
• Notify the healthcare provider of the client’s change in mental status.
• Include q2 hour’s reorientation in the client’s plan of care.
An older male comes to the clinic with a family member. When the nurse attempts to take the client’s health history,
he does not respond to questions in a clear manner. Which action should the nurse implement first?
• Assess the surroundings for noise and distractions.
The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4
hours. Based on this assessment, what should the nurse anticipate that client will need?
• Large amounts of fluid and electrolyte replacement.
121. Which intervention should the nurse include in the plan of care for a child with tetanus?
• Minimize the amount of stimuli in the room
122. Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic
overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client’s room. Best intervention?
• Remove cigarettes for the client’s room
123. A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What
information should the nurse provide? (Select all that apply.)
• A client must be willing to accept palliative care, not curative care.
• The healthcare provider must project that the client has 6 months or less to live.
124. A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse
include in this client’s teaching plan?
• Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
, 125. A nurse with 10 years experience working in the emergency room is reassigned to he perinatal unit to work an
8 hour shift. Which client is best to assign to this nurse?
• A mother with an infected episiotomy
126. An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic
with jugular vein distention. Which prescription should the nurse administer first?
• Digoxin.
127. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed
assistive personnel (UAP). Which task should the charge nurse assign to the RN?
• Supervise a newly hired graduate nurse during an admission assessment.
128. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the
distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action
should the nurse take?
• Ask the client what he is thinking about at his time.
129. After several hours of non-productive coughing, a client presents to the emergency room C/O of chest
tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and
diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement
bilaterally. Which actions should the nurse implement? (SATA)
Administer PRN nebulizer Obtain 12 lead Monitor continuous oxygen
treatment. electrocardiogram. saturation.
130. The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is
exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?
• Administer a prescribed analgesia for pain.
131. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes
methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about
caring for their child?
• Use sunblock or protective clothing when outdoors.
132. Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy.
Which actions should the nurse implement? (Select all that apply) Notify the food services department of the allergy.
Enter the allergy information in the client’s record. Add egg allergy to the client’s allergy arm band.
133.The rapid response team’s detects return of spontaneous circulation (ROSC) after 2 min of continuous chest
compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a
successful oral, intubation. What action should the nurse implement?
• Perform bilateral chest auscultation.
134. After administering an antipyretic medication. Which intervention should the nurse implement?
•Describe Encouraging radioactive liberal iodine fluid intakeas a tasteless, colorless medication administered by the
healthcare provider
135. A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be
included in preparing this client for this treatment?
