HESI RN EXIT EXAM QUESTIONS AND
VERIFIED ACCURATE SOLUTION |GET IT 100%
ACCURATE
Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach
the client's wrist restraints to the movable portion of the client's bed frame. What action should the
nurse take before leaving the room? - ANSWER-Ensure that the knot can be quickly released.
During a well baby , the nurse hides a block under the babies blanket, and the baby looks for the block.
Which normal growth and development milestone is the baby developing - ANSWER-object
permanenence
During an annual physical by the occupational RN working in a corporate clinic a male employee tells the
RN that his high stress job is causing trouble in his personal life. He further explains that he often gets so
angry while driving to and from work that he has considered "getting even" with other drivers. How
should the RN respond? - ANSWER-It sound as if there are many situations that make you feel angry
During the care of a client with Legionnaire's disease, which finding would require the nurse's
immediate attention - ANSWER-Decrease in chest wall expansion
Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain and
palpitation of the bladder indicates that it is distended and dull percussion. Even after assisting the
client to a standing position he is unable to void. What action should the nurse take? - ANSWER-prepare
to reinsert the urinary catheter
Enalapril Maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse
perform as a priority before administering medication? - ANSWER-Checking the clients blood pressure
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat
areas of redness ranging from pinpoint to 0.5cm in diameter. How should the nurse record this finding? -
ANSWER-Localized red rash comprised of flat areas pinpoint to 0.5cm in diameter
,Following an outbreak of measles involving 5 students in an elementary school, which action is most
important for the school nurse to take? - ANSWER-Restrict unvaccinated children from attending school
until measles outbreak is resolved.
Following and MVA a 3 year old girl has a spica cast applied. Which toy is best for the nurse for this 3 yr
old child - ANSWER-Set of cloth and hand puppets
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 or cream
Following surgical repair of the bladder a female client is being discharged from the hospital with an
indwelling catheter. Which instruction is most important for the nurse to provide to the client? -
ANSWER-Keep the drainage bag lower than the level of the bladder
In assessing a client who has a nursing diagnosis of spiritual distress. Which action should the nurse take
first? - ANSWER-Assist and support the client in establishing short term goals
In home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is
arranging for discharge the client verbalizes concerns about pain. What action should the nurse
implement - ANSWER-Provide client with a schedule of around the clock prescribed analgesic use
It is most important for the nurse to recalculate the Braden Scale for a client who has developed which
problem? - ANSWER-urinary incontinence
Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse
use to evaluate the effectiveness of this treatment? - ANSWER-a decrease in lethargy
Newly admitted pt with diagnosis of ascites. What order would the nurse question - ANSWER-High
sodium
Nurse in ED caring for a client who is having an acute asthma attack. How can she tell the client is in
respiratory distress - ANSWER--Wheezing
-retraction of sternal muscles
,Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and
benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse
emphasize concerning the installation of the antipyrine/ benzocaine otic solution? - ANSWER-Have the
child lie with the ear up for one to two minutes after installation.
Prior to initiating digital removal of fecal impaction it is important for the nurse to perform which
assessment? - ANSWER-Vital signs
The charge nurse observes a new graduate nurse demonstrate the administration of two different liquid
medications through a gtube used for continuous feeding What actions should the nurse take? -
ANSWER-- confirm that the nurse determined the amount of gastric residual
-Add the liquid volumes when documenting fluid intake
-Instruct the nurse to administer each medication separately
The charge nurse observes a new graduates performance of wound care. Which technique indicates the
employee is effectively cleaning the wound? - ANSWER-Starts at the wound site and moves outward
using circular motions
The charge nurse on a cardiac step down unit makes assignments for the team consisting of RN, a PN,
and an unlicensed person. Which client should be assigned to the PN? - ANSWER-a 58 year old
hypertensive with possible angina
The computer documentation system shuts down while the nurse is entering the client's physical
assessment data. What should the nurse do first? - ANSWER-Wait for notification services department
of the situation
The healthcare provider prescribes bladder irrigation to maintain patency of a clients indwelling
catheter. Which intervention should the nurse implement? - ANSWER-Use sterile syringe to irrigate the
normal saline 20ML
The healthcare provider prescribes vancomycin 500mg IV every 12 hours for a client with MRSA. Review
of the clients lab values shows that serum peak and trough levels are within the desired therapeutic
range and the serum creatinine level is 4.5 Which action should the nurse implement - ANSWER-
Withhold the nest scheduled dose and contact the healthcare provider
, The homehealth nurse is reviewing personal care needs of an elderly client who lives alone. Which client
assessment findings indicate the need to assign an unlicensed assistive personal to provide routine foot
care and file the clients toenails - ANSWER-- diminished visual acuity
-syncope when bending
-hand tremors
The measurement and documentation of vital signs is expected for clients in a long term facility. Which
staff type would it be a priority to delegate these tasks to - ANSWER-Unlicensed Assistive Personnel
The mother of a 12 month old with cystic fibrosis reports that her child is experiencing congestion
despite the use of CPT twice a day and has also experienced a loss of appetite. What instruction should
the nurse provide? - ANSWER-CPT should be performed more frequently, but at least an hour before
meals
The mother of a 2 year old tells the nurse that she is very concerned about her child because he has
developed "a will of his own" and "acts as if he can control others" The nurse provides information to
the mother to alleviate her concern recalling that according to Erikson, a toddler is confronting which
developmental task - ANSWER-Autonomy vs doubt and shame
The mother of a 9-month old infant calls the nurse at the pediatrician's office, tells the nurse that her
infant is teething, and asks what can be done to relieve the infants doscomfort. What should the nurse
instruct the mother to do? - ANSWER-Give the infant liquids or a popsicle and hard foods such as dry
toast
The mother of a child with tetralogy of Fallot asks the nurse "Why did this happen to my baby? What did
I do wrong?" Which response is most helpful? - ANSWER-This must be a very difficult time for you
The nurse assess a client who has a nasal cannula delivering oxygen at 2L/Min. To assess for skin
damage related to the cannula which area should the nurse observe - ANSWER-tops of ears, around the
nostrils, and over the cheeks
The nurse assesses a client for a pulse deficit and counts an apical pulse for 72 bpm and a radial pulse of
88 bpm. What action should the nurse take? - ANSWER-Obtain a second pulse deficit reading
VERIFIED ACCURATE SOLUTION |GET IT 100%
ACCURATE
Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach
the client's wrist restraints to the movable portion of the client's bed frame. What action should the
nurse take before leaving the room? - ANSWER-Ensure that the knot can be quickly released.
During a well baby , the nurse hides a block under the babies blanket, and the baby looks for the block.
Which normal growth and development milestone is the baby developing - ANSWER-object
permanenence
During an annual physical by the occupational RN working in a corporate clinic a male employee tells the
RN that his high stress job is causing trouble in his personal life. He further explains that he often gets so
angry while driving to and from work that he has considered "getting even" with other drivers. How
should the RN respond? - ANSWER-It sound as if there are many situations that make you feel angry
During the care of a client with Legionnaire's disease, which finding would require the nurse's
immediate attention - ANSWER-Decrease in chest wall expansion
Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain and
palpitation of the bladder indicates that it is distended and dull percussion. Even after assisting the
client to a standing position he is unable to void. What action should the nurse take? - ANSWER-prepare
to reinsert the urinary catheter
Enalapril Maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse
perform as a priority before administering medication? - ANSWER-Checking the clients blood pressure
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat
areas of redness ranging from pinpoint to 0.5cm in diameter. How should the nurse record this finding? -
ANSWER-Localized red rash comprised of flat areas pinpoint to 0.5cm in diameter
,Following an outbreak of measles involving 5 students in an elementary school, which action is most
important for the school nurse to take? - ANSWER-Restrict unvaccinated children from attending school
until measles outbreak is resolved.
Following and MVA a 3 year old girl has a spica cast applied. Which toy is best for the nurse for this 3 yr
old child - ANSWER-Set of cloth and hand puppets
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 or cream
Following surgical repair of the bladder a female client is being discharged from the hospital with an
indwelling catheter. Which instruction is most important for the nurse to provide to the client? -
ANSWER-Keep the drainage bag lower than the level of the bladder
In assessing a client who has a nursing diagnosis of spiritual distress. Which action should the nurse take
first? - ANSWER-Assist and support the client in establishing short term goals
In home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is
arranging for discharge the client verbalizes concerns about pain. What action should the nurse
implement - ANSWER-Provide client with a schedule of around the clock prescribed analgesic use
It is most important for the nurse to recalculate the Braden Scale for a client who has developed which
problem? - ANSWER-urinary incontinence
Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse
use to evaluate the effectiveness of this treatment? - ANSWER-a decrease in lethargy
Newly admitted pt with diagnosis of ascites. What order would the nurse question - ANSWER-High
sodium
Nurse in ED caring for a client who is having an acute asthma attack. How can she tell the client is in
respiratory distress - ANSWER--Wheezing
-retraction of sternal muscles
,Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and
benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse
emphasize concerning the installation of the antipyrine/ benzocaine otic solution? - ANSWER-Have the
child lie with the ear up for one to two minutes after installation.
Prior to initiating digital removal of fecal impaction it is important for the nurse to perform which
assessment? - ANSWER-Vital signs
The charge nurse observes a new graduate nurse demonstrate the administration of two different liquid
medications through a gtube used for continuous feeding What actions should the nurse take? -
ANSWER-- confirm that the nurse determined the amount of gastric residual
-Add the liquid volumes when documenting fluid intake
-Instruct the nurse to administer each medication separately
The charge nurse observes a new graduates performance of wound care. Which technique indicates the
employee is effectively cleaning the wound? - ANSWER-Starts at the wound site and moves outward
using circular motions
The charge nurse on a cardiac step down unit makes assignments for the team consisting of RN, a PN,
and an unlicensed person. Which client should be assigned to the PN? - ANSWER-a 58 year old
hypertensive with possible angina
The computer documentation system shuts down while the nurse is entering the client's physical
assessment data. What should the nurse do first? - ANSWER-Wait for notification services department
of the situation
The healthcare provider prescribes bladder irrigation to maintain patency of a clients indwelling
catheter. Which intervention should the nurse implement? - ANSWER-Use sterile syringe to irrigate the
normal saline 20ML
The healthcare provider prescribes vancomycin 500mg IV every 12 hours for a client with MRSA. Review
of the clients lab values shows that serum peak and trough levels are within the desired therapeutic
range and the serum creatinine level is 4.5 Which action should the nurse implement - ANSWER-
Withhold the nest scheduled dose and contact the healthcare provider
, The homehealth nurse is reviewing personal care needs of an elderly client who lives alone. Which client
assessment findings indicate the need to assign an unlicensed assistive personal to provide routine foot
care and file the clients toenails - ANSWER-- diminished visual acuity
-syncope when bending
-hand tremors
The measurement and documentation of vital signs is expected for clients in a long term facility. Which
staff type would it be a priority to delegate these tasks to - ANSWER-Unlicensed Assistive Personnel
The mother of a 12 month old with cystic fibrosis reports that her child is experiencing congestion
despite the use of CPT twice a day and has also experienced a loss of appetite. What instruction should
the nurse provide? - ANSWER-CPT should be performed more frequently, but at least an hour before
meals
The mother of a 2 year old tells the nurse that she is very concerned about her child because he has
developed "a will of his own" and "acts as if he can control others" The nurse provides information to
the mother to alleviate her concern recalling that according to Erikson, a toddler is confronting which
developmental task - ANSWER-Autonomy vs doubt and shame
The mother of a 9-month old infant calls the nurse at the pediatrician's office, tells the nurse that her
infant is teething, and asks what can be done to relieve the infants doscomfort. What should the nurse
instruct the mother to do? - ANSWER-Give the infant liquids or a popsicle and hard foods such as dry
toast
The mother of a child with tetralogy of Fallot asks the nurse "Why did this happen to my baby? What did
I do wrong?" Which response is most helpful? - ANSWER-This must be a very difficult time for you
The nurse assess a client who has a nasal cannula delivering oxygen at 2L/Min. To assess for skin
damage related to the cannula which area should the nurse observe - ANSWER-tops of ears, around the
nostrils, and over the cheeks
The nurse assesses a client for a pulse deficit and counts an apical pulse for 72 bpm and a radial pulse of
88 bpm. What action should the nurse take? - ANSWER-Obtain a second pulse deficit reading
