HESI EXIT 6 ICHS
2. When gathering for a group therapy session at 1400 hours, a female client complains to the
nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute
breaks were called over the unit intercom after breakfast and after lunch. The nurse is using
what communication technique in responding to the client?
a) Doubt
b) Observation
c) Confrontation
d) Reflection - Answer: d) Reflection
c) Confrontation
3. The nurse is interviewing a client with schizophrenia. Which client behavior requires
immediate intervention?
a) Lip smacking and frequent eye blinking
b) Shuffling gait and stooped posture
c) Rocks back and forth in the chair
d) Muscle spasms of the back and neck - Answer: d) Muscle spasms of the back and neck
4. A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain
and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra
Strength) every day. To assist the client with self-management of her pain, which information
should the nurse obtain?
a) Presence of bruising, weakness, or fatigue
b) Therapeutic exercise included in daily routine.
c) Average amount of protein eaten daily
d) Existence of gastrointestinal discomfort - Answer: b) Therapeutic exercise included in daily
routine.
d) Existence of gastrointestinal discomfort
5. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff
and one RN who was floated from a medical unit. The client with which condition is the best to
assign to the float nurse?
a) Diabetic ketoacidosis and titrated IV insulin infusion
b) Emphysema extubated 3 hours ago receiving heated mist
pg. 1
, c) Subdural hematoma with an intracranial monitoring device
d) Acute coronary syndrome treated with vasopressors - Answer: a) Diabetic ketoacidosis and
titrated IV insulin infusion
b) Emphysema extubated 3 hours ago receiving heated mist
9. A male client with renal cell carcinoma is returned to the unit following a radical
nephrectomy. The nurse notes that his vital signs and urine output are within normal range, his
bandage is dry, and the drain from the incision site is producing a small amount of
serasanguinous drainage. Which intervention should the nurse implement?
a) Place a pressure bandage at the drainage site
b) Document assessment findings in the electronic medical record
c) Monitor urinary catheter output for a decrease below 30 ml/hr
d) Notify surgeon of color and amount of wound drainage. - Answer: Notify surgeon of color
and amount of wound drainage
b) Document assessment findings in the electronic medical record
13. In evaluating the effectiveness of a postoperative client's intermittent pneumatic
compression devices, which assessment is most important for the nurse to complete?
a) Evaluate the client's ability to use an incentive spirometer
b) Monitor the amount of drainage from the client's incision
c) Observe both lower extremities for redness and swelling
d) Palpate all peripheral pulse points for volume and strength - Answer: Monitor the amount of
drainage from the client's incision
c) Observe both lower extremities for redness and swelling
17. Sublingual nitroglycerin is administered to a male client with instable angina who complains
of crushing chest pain. Five minutes later the client becomes nauseated and his blood pressure
drops to 60/40. Which intervention should the nurse implement?
a) Give a PRN antiemetic medication
b) Infuse a rapid IV normal saline bolus
c) Begin external chest compressions
d) Administer second dose of nitroglycerin - Answer: infuse a rapid IV normal saline bolus
pg. 2
2. When gathering for a group therapy session at 1400 hours, a female client complains to the
nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute
breaks were called over the unit intercom after breakfast and after lunch. The nurse is using
what communication technique in responding to the client?
a) Doubt
b) Observation
c) Confrontation
d) Reflection - Answer: d) Reflection
c) Confrontation
3. The nurse is interviewing a client with schizophrenia. Which client behavior requires
immediate intervention?
a) Lip smacking and frequent eye blinking
b) Shuffling gait and stooped posture
c) Rocks back and forth in the chair
d) Muscle spasms of the back and neck - Answer: d) Muscle spasms of the back and neck
4. A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain
and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra
Strength) every day. To assist the client with self-management of her pain, which information
should the nurse obtain?
a) Presence of bruising, weakness, or fatigue
b) Therapeutic exercise included in daily routine.
c) Average amount of protein eaten daily
d) Existence of gastrointestinal discomfort - Answer: b) Therapeutic exercise included in daily
routine.
d) Existence of gastrointestinal discomfort
5. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff
and one RN who was floated from a medical unit. The client with which condition is the best to
assign to the float nurse?
a) Diabetic ketoacidosis and titrated IV insulin infusion
b) Emphysema extubated 3 hours ago receiving heated mist
pg. 1
, c) Subdural hematoma with an intracranial monitoring device
d) Acute coronary syndrome treated with vasopressors - Answer: a) Diabetic ketoacidosis and
titrated IV insulin infusion
b) Emphysema extubated 3 hours ago receiving heated mist
9. A male client with renal cell carcinoma is returned to the unit following a radical
nephrectomy. The nurse notes that his vital signs and urine output are within normal range, his
bandage is dry, and the drain from the incision site is producing a small amount of
serasanguinous drainage. Which intervention should the nurse implement?
a) Place a pressure bandage at the drainage site
b) Document assessment findings in the electronic medical record
c) Monitor urinary catheter output for a decrease below 30 ml/hr
d) Notify surgeon of color and amount of wound drainage. - Answer: Notify surgeon of color
and amount of wound drainage
b) Document assessment findings in the electronic medical record
13. In evaluating the effectiveness of a postoperative client's intermittent pneumatic
compression devices, which assessment is most important for the nurse to complete?
a) Evaluate the client's ability to use an incentive spirometer
b) Monitor the amount of drainage from the client's incision
c) Observe both lower extremities for redness and swelling
d) Palpate all peripheral pulse points for volume and strength - Answer: Monitor the amount of
drainage from the client's incision
c) Observe both lower extremities for redness and swelling
17. Sublingual nitroglycerin is administered to a male client with instable angina who complains
of crushing chest pain. Five minutes later the client becomes nauseated and his blood pressure
drops to 60/40. Which intervention should the nurse implement?
a) Give a PRN antiemetic medication
b) Infuse a rapid IV normal saline bolus
c) Begin external chest compressions
d) Administer second dose of nitroglycerin - Answer: infuse a rapid IV normal saline bolus
pg. 2
