HESI RN EXIT EXAM QUESTIONS AND VERIFIED
ACCURATE SOLUTION |GET IT 100% ACCURATE
A teenager presents to the Emergency Department with palpitations after vaping at a party. The client is
anxious, fearful, and hyperventilating. The nurse anticipates the client is developing which acid base
imbalance - ANSWER-Respiratory Alkalosis
A two year old child is brought to the healthcare providers office with a chief complaint of mild diarrhea
for 2 days. Nutritional counseling by the nurse should include which statement? - ANSWER-Continue
with regular diet and give oral rehydration fluids
A two year old with Down Syndrome is brought to the clinic for his regular physical exam. The nurse
knows which problem is frequently associated with Down Syndrome? - ANSWER-Congenital Heart
Disease
A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a
home pregnancy test to diagnose pregnancy. Which response is best? - ANSWER-a home pregnancy test
can be used right after your first missed period
A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a
government official being followed by spies. On further questioning he reveals his warnings must be
headed to prevent a nuclear war. What is the most therapeutic approach by the nurse - ANSWER-Listen
quietly without comment
A young male client with testicular cancer has a living will that describes his desire that no extraordinary
measures be taken to save his life. The healthcare provider knows the client has a good prognosis and
refuses to write a do not resuscitate prescription. What action should the nurse take? - ANSWER-Initiate
an ethics committee review of the case
After 2 days treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is
infusing, and the child's urine output is 50 mL/hour. During morning assessment, the nurse determines
that the child is lethargic and difficult to arouse. Which action should the nurse implement? - ANSWER-
perform a fingerstick glucose test
,After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops
pontine myselinolysis. Which intervention should the nurse implement first? - ANSWER-Reorientate
client to his room
After an inservice about electronic health record (EHR) security and safeguarding client information, the
nurse observes a colleague going home with printed copies of client information in a uniform pocket.
Which action should the nurse take? - ANSWER-File a detailed incident report with the specific hiring
facility
After experiencing symptoms caused by an abnormal heart rhythm a client is placed on a temporary
pacemaker. When the client expresses concern and fear of the pacemaker how should the nurse
respond? - ANSWER-Encourage discussion about the concerns and fears
After receiving IV fluids in the Emergency Department and elderly client is admitted to the acute care
with a medical diagnosis of dehydration. The client is receiving 0.9% normal saline at 125ml/hr via saline
lock and has a bounding pulse, tachycardia, and pedal edema. When contacting the healthcare provider
the nurse anticipates what intervention - ANSWER-Remove the saline lock from the clients arm
After receiving report on an inpatient acute care unit, Which client should the nurse assess first? -
ANSWER-The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
After taking orlistat (Xenical) for one week a femela client tells the home health nurse that she is
experiencing increasingly frequent oily stools and flatus. What action should the nurse take? - ANSWER-
ask the client to describe her dietary intake history for the last several days
An adult client with primary Raynauds phenomenon develops pallor and then cyanosis of her finger.
After warming her hands the fingers turn red and the client reports a burning sensation. What action
should the nurse take? - ANSWER-secure a pulse oximeter to monitor the clients oxygen saturation
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should be the
nurse's first response? - ANSWER-It is important that you continue your medication while learning to
meditate.
,An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the Emergency Department prior to his transfer to the ICU
the nurse notes that the suction control chamber is bubbling at the - 10cm H2O mark with fluctuation in
the water seal and over the past hour 75ml of bright red blood is measured in the collection chamber.
Which intervention should the nurse implement? - ANSWER-Add sterile water to the suction control
chamber
An emergency department nurse is monitoring a client with suspected acute myocardial infarction (MI)
who is awaiting transfer to the Coronary Intensive Care Unit. The nurse notes the sudden onset of
premature ventricular contractions (PVCs) on the monitor, checks the clients carotid pulse and
determines the PVCs are not resulting in perfusion. The appropriate action by the nurse is to - ANSWER-
Ask the ED physician to check the client
An infant with Tetralogy of fallot becomes acutely cyanotic and hyperpneic which action should the
nurse implement first - ANSWER-Place the infant in a knee chest position
An older adult female is admitted to the ICU with a possible stroke is intubated with ventilator setting of
tidal volume 600 PIO2 40% and respiratory rate of 12 breaths/min. The ABG results after intubation are
PH 7.31 PaCO2 60 PaO2 104, SPO2 98%, HCO3 23. To normalize the clients ABG findings which action is
required - ANSWER-Increase ventilator rate
An older adult is admitted with fluid volume deficit and dehydration. Which assessment finding is the
best indicator of hydration that the nurse should report to the healthcare provider? - ANSWER-Skin
tenting occurs when the client's forearm is pinched
An older adult male is admitted to the medical unit following a fall at home. When undressing him the
nurse finds that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What
action should the nurse implement first? - ANSWER-Determine the size and depth of the skin
breakdown over the sacral area
An older adult male is admitted with complications related to COPD. He reports progressive dyspnea
that worsens on exertion and his weakness ahs increased over the past month. The nurse notes the he
has dependent edema in both lower legs. Based on these findings which dietary instruction should the
nurse provide? - ANSWER-Restrict daily fluid intake
, An older adult with a long hx of COPD is admitted with progressive shortness of breath and a persistent
cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse
implement? - ANSWER-Apply a high flow venturi mask
An older client is admitted for repair of a broken hip. To reduce the risk for infection during the post op
period, which nursing intervention should the nurse include in the clients plan of care - ANSWER--teach
the client to use incentive spirometer every 2 hours while awake
-remove urinary catheter as soon as possible and encourage voiding
AN otoscope exam of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging and
not movable. What action should the nurse take next? - ANSWER-Ask the child if he has has a cold,
runny nose or any ear pain lately
An overweight, young adult male who was recently diagnosed with type 2 diabetes mellitus is admitted
for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the
nurse implement? - ANSWER-- assess his skin temp and moisture
- document anxiety on the surgical checklist
-administer a PRN dose of regular insulin
An RN from a woman's wellness health clinic is temporarily reassigned to an adult medical unit. Which
of these client assignments would be appropriate for this nurse? - ANSWER-A client from a motor
vehicle accident with an external fixation device on the leg
An unlicensed assistive personnel is assigned to help a female client with her bath who has viral
hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with UAP? -
ANSWER-Wear gloves while giving a bath
At 0100 on a male clients second postoperative night the client states he is unable to sleep and plans to
read to feel sleepy. What action should the nurse implement - ANSWER-Bring the client a prescribed
PRN sedative-hypnotic
At 14 weeks gestation a client arrives at the Emergency Department complaining of a dull pain in the
right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. 30 mins
after admission the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment
ACCURATE SOLUTION |GET IT 100% ACCURATE
A teenager presents to the Emergency Department with palpitations after vaping at a party. The client is
anxious, fearful, and hyperventilating. The nurse anticipates the client is developing which acid base
imbalance - ANSWER-Respiratory Alkalosis
A two year old child is brought to the healthcare providers office with a chief complaint of mild diarrhea
for 2 days. Nutritional counseling by the nurse should include which statement? - ANSWER-Continue
with regular diet and give oral rehydration fluids
A two year old with Down Syndrome is brought to the clinic for his regular physical exam. The nurse
knows which problem is frequently associated with Down Syndrome? - ANSWER-Congenital Heart
Disease
A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a
home pregnancy test to diagnose pregnancy. Which response is best? - ANSWER-a home pregnancy test
can be used right after your first missed period
A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a
government official being followed by spies. On further questioning he reveals his warnings must be
headed to prevent a nuclear war. What is the most therapeutic approach by the nurse - ANSWER-Listen
quietly without comment
A young male client with testicular cancer has a living will that describes his desire that no extraordinary
measures be taken to save his life. The healthcare provider knows the client has a good prognosis and
refuses to write a do not resuscitate prescription. What action should the nurse take? - ANSWER-Initiate
an ethics committee review of the case
After 2 days treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is
infusing, and the child's urine output is 50 mL/hour. During morning assessment, the nurse determines
that the child is lethargic and difficult to arouse. Which action should the nurse implement? - ANSWER-
perform a fingerstick glucose test
,After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops
pontine myselinolysis. Which intervention should the nurse implement first? - ANSWER-Reorientate
client to his room
After an inservice about electronic health record (EHR) security and safeguarding client information, the
nurse observes a colleague going home with printed copies of client information in a uniform pocket.
Which action should the nurse take? - ANSWER-File a detailed incident report with the specific hiring
facility
After experiencing symptoms caused by an abnormal heart rhythm a client is placed on a temporary
pacemaker. When the client expresses concern and fear of the pacemaker how should the nurse
respond? - ANSWER-Encourage discussion about the concerns and fears
After receiving IV fluids in the Emergency Department and elderly client is admitted to the acute care
with a medical diagnosis of dehydration. The client is receiving 0.9% normal saline at 125ml/hr via saline
lock and has a bounding pulse, tachycardia, and pedal edema. When contacting the healthcare provider
the nurse anticipates what intervention - ANSWER-Remove the saline lock from the clients arm
After receiving report on an inpatient acute care unit, Which client should the nurse assess first? -
ANSWER-The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
After taking orlistat (Xenical) for one week a femela client tells the home health nurse that she is
experiencing increasingly frequent oily stools and flatus. What action should the nurse take? - ANSWER-
ask the client to describe her dietary intake history for the last several days
An adult client with primary Raynauds phenomenon develops pallor and then cyanosis of her finger.
After warming her hands the fingers turn red and the client reports a burning sensation. What action
should the nurse take? - ANSWER-secure a pulse oximeter to monitor the clients oxygen saturation
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should be the
nurse's first response? - ANSWER-It is important that you continue your medication while learning to
meditate.
,An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the Emergency Department prior to his transfer to the ICU
the nurse notes that the suction control chamber is bubbling at the - 10cm H2O mark with fluctuation in
the water seal and over the past hour 75ml of bright red blood is measured in the collection chamber.
Which intervention should the nurse implement? - ANSWER-Add sterile water to the suction control
chamber
An emergency department nurse is monitoring a client with suspected acute myocardial infarction (MI)
who is awaiting transfer to the Coronary Intensive Care Unit. The nurse notes the sudden onset of
premature ventricular contractions (PVCs) on the monitor, checks the clients carotid pulse and
determines the PVCs are not resulting in perfusion. The appropriate action by the nurse is to - ANSWER-
Ask the ED physician to check the client
An infant with Tetralogy of fallot becomes acutely cyanotic and hyperpneic which action should the
nurse implement first - ANSWER-Place the infant in a knee chest position
An older adult female is admitted to the ICU with a possible stroke is intubated with ventilator setting of
tidal volume 600 PIO2 40% and respiratory rate of 12 breaths/min. The ABG results after intubation are
PH 7.31 PaCO2 60 PaO2 104, SPO2 98%, HCO3 23. To normalize the clients ABG findings which action is
required - ANSWER-Increase ventilator rate
An older adult is admitted with fluid volume deficit and dehydration. Which assessment finding is the
best indicator of hydration that the nurse should report to the healthcare provider? - ANSWER-Skin
tenting occurs when the client's forearm is pinched
An older adult male is admitted to the medical unit following a fall at home. When undressing him the
nurse finds that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What
action should the nurse implement first? - ANSWER-Determine the size and depth of the skin
breakdown over the sacral area
An older adult male is admitted with complications related to COPD. He reports progressive dyspnea
that worsens on exertion and his weakness ahs increased over the past month. The nurse notes the he
has dependent edema in both lower legs. Based on these findings which dietary instruction should the
nurse provide? - ANSWER-Restrict daily fluid intake
, An older adult with a long hx of COPD is admitted with progressive shortness of breath and a persistent
cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse
implement? - ANSWER-Apply a high flow venturi mask
An older client is admitted for repair of a broken hip. To reduce the risk for infection during the post op
period, which nursing intervention should the nurse include in the clients plan of care - ANSWER--teach
the client to use incentive spirometer every 2 hours while awake
-remove urinary catheter as soon as possible and encourage voiding
AN otoscope exam of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging and
not movable. What action should the nurse take next? - ANSWER-Ask the child if he has has a cold,
runny nose or any ear pain lately
An overweight, young adult male who was recently diagnosed with type 2 diabetes mellitus is admitted
for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the
nurse implement? - ANSWER-- assess his skin temp and moisture
- document anxiety on the surgical checklist
-administer a PRN dose of regular insulin
An RN from a woman's wellness health clinic is temporarily reassigned to an adult medical unit. Which
of these client assignments would be appropriate for this nurse? - ANSWER-A client from a motor
vehicle accident with an external fixation device on the leg
An unlicensed assistive personnel is assigned to help a female client with her bath who has viral
hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with UAP? -
ANSWER-Wear gloves while giving a bath
At 0100 on a male clients second postoperative night the client states he is unable to sleep and plans to
read to feel sleepy. What action should the nurse implement - ANSWER-Bring the client a prescribed
PRN sedative-hypnotic
At 14 weeks gestation a client arrives at the Emergency Department complaining of a dull pain in the
right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. 30 mins
after admission the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment
