Hesi Exit Exam

HESI EXIT EXAM EXAM QUESTIONS AND CORRECT VERIFIED ANSWERS 100% PASS (A+) 1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? - Answer Review with the client the need to avoid foods that are rich in milk and cream 2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? - Answer Stroke secondary to haemorrhage 3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? - Answer Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. 4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? - Answer Describes life without purpose 5. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolaou (Pap) smear results are negative. What information should the nurse include in the client's teaching plan? - Answer Further evaluation involving surgery may be needed 6. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? - Answer Teach tracheal suctioning techniques 7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement? - Answer Document the assessment data 8. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? - Answer Respiratory apnoea of 30 seconds 9. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? - Answer Check the client for lacerations or fractures 10. At 0600 while admitting a woman for a schedule repeat caesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? - Answer Inform the anaesthesia care provider 11. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? - Answer Listen with the bell at the same location 12. A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? - Answer Medicare 13. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? - Answer Toasted wheat bread and jelly 14. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? - Answer "I have a headache that gets worse when I sit up" 15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? - Answer Obtain a clean catch mid-stream specimen 16. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child? - Answer Foods sweetened with aspartame 17. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? - Answer Direct the nurse to continue the surgical hand scrub for a 5-minute duration 18. Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis? - Answer Bagel with jelly and skim milk 19. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? - Answer An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied 20. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the paediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? - Answer Cleanse the foot with soap and water and apply an antibiotic ointment 21. The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide? - Answer Stop using the ointment and encourage complete drying of the feet and wearing clean socks. 22. A 26-year-old female client is admitted to the hospital for treatment of a simple goitre, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences - Answer Palpitations and shortness of breath 23. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? - Answer Obtain a list of medications taken for cardiac history 24. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) - Answer 75 ml/hour 25. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) - Answer Fluid shifts from intravascular to interstitial area due to decreased serum protein Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen Increased circulating aldosterone levels that increase sodium and water retention 26. The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) - Answer Murmur 27. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labelled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth) - Answer 0.4 ml 28. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? - Answer Auscultate the client's bowel sounds 29. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? - Answer Ask the client to discuss "do not resuscitate" with her healthcare provider 30. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? - Answer Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour 31. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? - Answer Have you noticed any changes in your fingernails? 32. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? - Answer Capillary refill of 8 seconds 33. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse's signature on the client's surgical consent form? (Select all that apply) - Answer The client voluntarily grants permission for the procedure to be done The client is competent to sign the consent without impairment of judgment The client understands the risks and benefits associated with the procedure 34. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? - Answer Advise the client that assignments are not based on clients’ requests 35. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? - Answer Place the implant in a lead container using long-handled forceps 36. The client with which type of wound is most likely to need immediate intervention by the nurse? - Answer Laceration 37. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care? - Answer Monitor blood pressure frequently 38. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? - Answer To reduce abdominal pressure on the diaphragm 39. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? - Answer The gallbladder is normal 40. A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? - Answer Inform her that some antianxiety medications are safe to take while breastfeeding 41. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? - Answer Start an intravenous (IV) infusion of normal saline 42. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication? - Answer The additive effect of multiple medications has caused the blood pressure to drop too low 43. Which client is at the greatest risk for developing delirium? - Answer An adult client who cannot sleep due to constant pain. 44. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? - Answer Reduce risks factors for infection 45. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? - Answer A business and professional women's group. 46. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement? - Answer Measure vital signs 47. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? - Answer Serum calcium 48. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? - Answer The technique is intended to maintain straight spinal alignment. 49. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client? - Answer Baked apples topped with dried raisins 50. Which action should the school nurse take first when conducting a screening for scoliosis? - Answer Inspect for symmetrical shoulder height. 51. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a