2018 HESI EXIT V3

1. A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse? A) Explain to the client that the dentures must come out as they may get lost or broken in the operating room B) Ask the client if there are second thoughts about having the procedure C) Notify the anesthesia department and the surgeon of the client's refusal D) Ask the client if the preference would be to remove the dentures in the operating room receiving area The correct answer is D: Ask the client if the preference would be to remove the dentures in the operating room receiving area 2. The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning? A) Performance on written tests B) Responses to verbal questions C) Completion of a mailed survey D) Reported behavioral changes The correct answer is D: Reported behavioral changes 3. The nurse is planning care for an 18 month-old child. Which action should be included in the child's care? A) Hold and cuddle the child frequently B) Encourage the child to feed himself finger food C) Allow the child to walk independently on the nursing unit D) Engage the child in games with other children The correct answer is B: Encourage the child to feed himself finger food 4. A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events B) Detaching or dissociating in this way postpones painful feelings C) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflict D) To isolate the feelings in this way reduces conflict within the client and with others The correct answer is A: Such fantasies can gratify unconscious wishes or prepare for anticipated future events 5. An appropriate goal for a client with anxiety would be to A) Ventilate anxious feelings to the nurse B) Establish contact with reality C) Learn self-help techniques D) Become desensitized to past trauma The correct answer is C: Learn self-help techniques 6. While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best? A) "That's OK, its all right to skip your medication now and then." B) "I will have to call your doctor and report this." C) "Is there a reason why you don't want to take your medicine?" D) "Do you understand the consequences of refusing your prescribed treatment?" The correct answer is C: "Is there a reason why you don't want to take your medicine?" 7. While caring for a client, the nurse notes a pulsating mass in the client's peri umbilical area. Which of the following assessments is appropriate for the nurse to perform? A) Measure the length of the mass B) Auscultate the mass C) Percuss the mass D) Palpate the mass The correct answer is B: Auscultate the mass 8. A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? A) "Good morning. Do you remember where you are?" B) "Hello. My name is Elaine Jones and I am your nurse for today." C) "How are you today? Remember, you're in the hospital." D) "Good morning. You’re in the hospital. I am your nurse Elaine Jones." The correct answer is D: "Good morning. 9. The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age? A) Formula or breast milk B) Dilute nonfat dry milk C) Warmed fruit juice D) Fluoridated tap water The correct answer is A: Formula or breast milk 10. The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children? A) Growth problems will occur if the fracture involves the periosteum B) Epiphyseal fractures often interrupt a child's normal growth pattern C) Children usually heal very quickly, so growth problems are rare D) Adequate blood supply to the bone prevents growth delay after fractures The correct answer is B: Epiphyseal fractures often interrupt a child''s normal growth pattern 11. The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)? A) April 8 B) January 15 C) February 11 D) December 23 The correct answer is D: December 23 12. When screening children for scoliosis, at what time of development would the nurse expect early signs to appear? A) Prenatally on ultrasound B) In early infancy C) When the child begins to bear weight D) During the preadolescent growth spurt The correct answer is D: During the preadolescent growth spurt 13. A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action? A) Discharge the client from home health care related to noncompliance B) Notify the health care provider of the client's failure to follow prescribed diet C) Discuss diet with the client to learn the reasons for not following the diet D) Make a referral to Meals-on-Wheels The correct answer is C: Discuss diet with client to learn the reasons for not following the diet 14. A client states, "People think I’m no good, you know what I mean?" Which of these responses would be most therapeutic? A) "Well people often take their own feelings of inadequacy out on others." B) "I think you’re good. So you see, there’s one person who likes you." C) "I’m not sure what you mean. Tell me a bit more about that." D) "Let's discuss this to see the reasons to create this impression on people?" The correct answer is C: "I’m not sure what you mean. Tell me a bit more about that." 15. A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of these is the best nursing diagnosis? A) Noncompliance related to medication side effects B) Knowledge deficit related to misunderstanding of disease state C) Defensive coping related to chronic illness D) Altered health maintenance related to occupation The correct answer is A: Noncompliance related to medication side effects 16. When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend? A) Biofeedback B) Deep breathing C) Distraction D) Imagery The correct answer is B: Deep breathing 17. When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in? A) Competitive board games with older children B) Playing with their own toys along side with other children C) Playing alone with hand held computer games D) Playing cooperatively with other preschoolers The correct answer is D: Playing cooperatively with other preschoolers 18. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding? A) Hold a rattle B) Bang two blocks C) Drink from a cup D) Wave "bye-bye" The correct answer is A: Hold a rattle 19. When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child? A) Provide a verbal explanation just prior to the surgery B) Provide the child with a booklet to read about the surgery C) Introduce the child to another child who had heart surgery 3 days ago D) Explain the surgery using a model of the heart The correct answer is D: Explain the surgery using a model of the heart 20. The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments? A) Focus on the child's needs and recovery B) Explain the cause of the child's illness C) Acknowledge that early care would have been better D) Accept their feelings without judgment The correct answer is D: Accept their feelings without judgment 21. When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? A) Record the number of stools per day B) Maintain strict intake and output records C) Sterile technique for dressing change at IV site D) Monitor for cardiac arrhythmias The correct answer is C: Sterile technique for dressing change at IV site 22. When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery after a myocardial infarction, which finding would be of greatest concern to the nurse? A) Sero sanginous drainage from gums B) Hematemesis C) Pink frothy sputum D) Slight red color at urine The correct answer is B: Hematemesis 23. A 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion was initiated, the client complains of chills and headache. Which action should the nurse implement first? A) Notify the health care provider B) Check the client's temperature C) Stop the transfusion D) Obtain a urine specimen The correct answer is C: Stop the transfusion 24. An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which order should be questioned by the nurse? A) Passive range of motion B) Replacement of factor VIII C) Aspirin for pain management D) Immobilization splint The correct answer is C: Aspirin for pain management 25. The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching? A) "Nystatin should be given 4 times a day after my baby eats." B) "I will boil the nipples and pacifiers for twenty minutes." C) "I should be taking the medication prescribed for this infection." D) "The therapy can be discontinued when the spots disappear." The correct answer is D: "The therapy can be discontinued when the spots disappear." 26. The nurse is preparing a client for discharge following in-patient treatment for pulmonary tuberculosis. Which of these instructions should be given to the client? A) Continue medication until findings are relieved B) Continue medication use as prescribed C) Avoid contact with children, pregnant women or immune depressed persons D) Take medication with Amphogel if epigastric distress occurs The correct answer is B: Continue medication use as prescribed 27. The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's immediate attention? A) "I have a burning sensation when I urinate." B) "I have soreness and aching in my muscles." C) "I am itching all over." D) "I have cramping in my stomach." The correct answer is C: "I am itching all over." 28. A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the treatment. What should the nurse discuss with the client as part of the teaching plan? A) Risks of oral contraceptives B) Reduction in exercise program C) Avoidance of alcohol D) Cessation of smoking The correct answer is C: Avoidance of alcohol 29. The nurse prepares to administer eye drops to a 6 year-old child. Which of these demonstrates the correct method for instillation of eye drops? A) Directly on the anterior surface of the eyeball B) In the corner where the lids meet C) Under the upper lid as it is pulled upward D) In the conjunctival sac as the lower lid is pulled down The correct answer is D: In the conjunctival sac as the lower lid is pulled down 30. A depressed client is experiencing severe insomnia. The health care provider orders trazadone (Desyrel). The nurse tells the client to expect A) Improvement of acne B) Relief of insomnia C) Reduced arthritic pain D) Less nasal stuffiness The correct answer is B: Relief of insomnia 31. A client with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client's symptoms of excessive hunger and thirst, what would the nurse expect the health care provider to order? A) Orange juice B) Regular insulin C) NPH Insulin D) Repeat blood sugar level The correct answer is B: Regular insulin 32. The nurse is planning to administer otic drops to a 6 year-old child. Which of the following is the correct procedure? A) Hold the pinna up and back to instill the drops B) Place several drops in the outer ear C) Insert cotton in the outer ear after giving medication D) Assist the child to lie on the affected side afterwards The correct answer is A: Hold the pinna up and back to instill the drops 33. A 1 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? A) Use aseptic technique during dressing changes B) Maintain central line catheter integrity C) Monitor serum glucose levels D) Check results of liver function tests The correct answer is C: Monitor serum glucose levels 34. Today's prothrombin time for a client receiving Coumadin is 20 (normal range listed by the lab is 10-14). What is the appropriate nursing action? A) Notify the health care provider immediately B) Recognize that this is a therapeutic level C) Observe the client for hematoma development D) Assess for bleeding at gums or IV sites The correct answer is B: Recognize that this is a therapeutic level 35. The nurse administered intravenous gamma globulin to an 18 month-old child with AIDS. The parent asks why this medication is being given. What is the nurse’s best response? A) "It will slow down the replication of the virus." B) "This medication will improve your child's overall health status." C) "This medication is used to prevent bacterial infections." D) "It will increase the effectiveness of the other medications your child receives." The correct answer is C: "This medication is used to prevent bacterial infections." 36. The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse's immediate attention? A) Temperature of 37.5 degrees Celsius B) Urine output of 300 cc in 4 hours C) Poor skin turgor D) Blood glucose of 350 mg/dl The correct answer is D: Blood glucose of 350 mg/dl 37. The nurse is teaching a client with asthma about the correct use of the Azmacort (triamcinolone) inhaler. Which of the following statements, if made by the client, would indicate that the teaching was effective? A) "The inhaler can be used whenever I feel short of breath." B) "I should rinse my mouth after using the inhaler." C) "If I forget a dose, I can double up on the next dose." D) I should not use a spacer with my Azmacort. The correct answer is B: "I should rinse my mouth after using the inhaler." 38. A client is admitted to the hospital because of heart failure and digoxin toxicity. At home, the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which symptom would the nurse anticipate finding on the initial assessment? * A) Muscle weakness and cramping B) Confusion C) Blood in the urine D) Tinnitis The correct answer is A: Muscle weakness and cramping 39. The nurse admits a client with hypertension who complains of dizziness after taking diltiazem (Cardizem). Which of the following is the most important information for the nurse to assess? A) Schedule for taking medicine B) Daily intake of potassium C) Activity and rest patterns D) Baseline heart rate Review Information: The correct answer is A: Schedule for taking medicine 40. Which of the following classifications of medications would be most often used for clients with schizophrenia? A) Anti-depressants B) Mood stabilizers C) Anxiolytics D) Neuroleptics The correct answer is D: Neuroleptics 41. A hospitalized 8 month-old infant is receiving digoxin for the treatment of Tetralogy of Fallot. Prior to administering the next dose of medication, the parent reports that the baby has vomited one time, just after breakfast. The heart rate is 62. What is the initial response of the nurse? A) Give the dose after lunch B) Reduce the next dose by half C) Double the next dose * D) Hold the medication The correct answer is D: Hold the medication 42. A child is treated with edetate calcium disodium (Calcium EDTA) for lead poisoning. Which of these should the nurse assess first ? A) Serum potassium level B) Blood calcium level C) Urinary output D) Deep tendon reflexes The correct answer is C: Urinary output