HESI RN EXIT
EXAM
,The nurse is giving preop instructions to a 14 yr old scheduled to correct a spinal
curvature. Which statement best demonstrates that learning has taken place? -
CORRECT ANSWERS-I understand I will be in a body cast and I will show you hoy you
taught me to turn
To take the vital signs of a 4 month old child which order will give the most accurate
results? - CORRECT ANSWERS-Respiratory rate, heart rate, rectal temperature
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? - CORRECT
ANSWERS-Ask the child if he has has a cold, runny nose or any ear pain lately
Which restraint should be used for a toddler after a cleft palate repair? - CORRECT
ANSWERS-elbow
What preoperative nursing intervention should be included in the plan of care for an
infant with pyloric stenosis? - CORRECT ANSWERS-Observe for projectile vomiting
A six month old returns from surgery with elbow restraints in place. What nursing
intervention should be included when caring for any restrained child? - CORRECT
ANSWERS-remove restraints one at a time and provide range of motion exercise
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? -
CORRECT ANSWERS-Congenital Heart Disease
When assessing a child with asthma the nurse should expect intercostal retractions
during - CORRECT ANSWERS-inspiration
When planning the care for a child who has had a cleft lip repair, the nurse knows that
crying should be minimized because it - CORRECT ANSWERS-stresses the suture line
A client with a productive cough has obtained a sputum specimen for culture as
instructed. What action is the best initial nursing action? - CORRECT ANSWERS-
Administer the first dose of prescribed antibiotic therapy
A client is brought to the Emergency Department by ambulance in cardiac arrest with
CPR in progress. The client is intubated and receiving 100% O2 per ambu bag. The
nurse determines the client is cyanotic, cold, and diaphoretic. Which assessment is
most important to obtain? - CORRECT ANSWERS-deep tendon reflexes
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a
client develops pontine myselinolysis. Which intervention should the nurse implement
first? - CORRECT ANSWERS-Reorientate client to his room
, A male client with heart failure (HF) calls the clinic and reports he cannot put his shoes
on because they are too tight. Which additional information should the nurse obtain? -
CORRECT ANSWERS-Has his weight changed in the last several days
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? - CORRECT ANSWERS-Apply a high flow
venturi mask
A client with a hx of asthma and bronchitis arrives at the clinic with SOB, productive
cough with thickened tenacious mucous and the inability to walk up a flight of stairs
without experiencing breathlessness. Which action is important for the nurse to instruct
the client about self care? - CORRECT ANSWERS-Increase the daily intake of oral
fluids to to liquefy secretions
A cardiac catherization of a client with heart disease indicates the following blockages
95% LAD 99% proximal circumflex and 95% proximal RCA. The client later asks the
nurse "what does all that mean for me" - CORRECT ANSWERS-3 main arteries have
major blockages with only 1 to 5% of blood flow getting through to the heart muscle
The nurse is caring for a client with a lower left pulmonary abscess which position
should the nurse instruct the client to maintain - CORRECT ANSWERS-left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable
to eat or drink without nausea and vomiting. Which finding should the nurse report to the
healthcare provider - CORRECT ANSWERS-yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a
neuro assessment every 4 hours. which assessment finding warrants immediate
intervention by the nurse? - CORRECT ANSWERS-Increasing Anxiety
The nurse is providing preoperative education for a Jewish client scheduled to receive a
xenograft to promote burn healing. Which info should the nurse provide this client? -
CORRECT ANSWERS-The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requests assistance to
reposition. The wound dehiscences and eviscerates. The nurse moistens an available
sterile dressing and places it over the wound which intervention should the nurse
implement next? - CORRECT ANSWERS-prepare the client to return to the operating
room
A client with carcinoma of the lung is complaining of weakness and has a serum sodium
level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan
of care? - CORRECT ANSWERS-Fluid volume excess
EXAM
,The nurse is giving preop instructions to a 14 yr old scheduled to correct a spinal
curvature. Which statement best demonstrates that learning has taken place? -
CORRECT ANSWERS-I understand I will be in a body cast and I will show you hoy you
taught me to turn
To take the vital signs of a 4 month old child which order will give the most accurate
results? - CORRECT ANSWERS-Respiratory rate, heart rate, rectal temperature
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? - CORRECT
ANSWERS-Ask the child if he has has a cold, runny nose or any ear pain lately
Which restraint should be used for a toddler after a cleft palate repair? - CORRECT
ANSWERS-elbow
What preoperative nursing intervention should be included in the plan of care for an
infant with pyloric stenosis? - CORRECT ANSWERS-Observe for projectile vomiting
A six month old returns from surgery with elbow restraints in place. What nursing
intervention should be included when caring for any restrained child? - CORRECT
ANSWERS-remove restraints one at a time and provide range of motion exercise
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? -
CORRECT ANSWERS-Congenital Heart Disease
When assessing a child with asthma the nurse should expect intercostal retractions
during - CORRECT ANSWERS-inspiration
When planning the care for a child who has had a cleft lip repair, the nurse knows that
crying should be minimized because it - CORRECT ANSWERS-stresses the suture line
A client with a productive cough has obtained a sputum specimen for culture as
instructed. What action is the best initial nursing action? - CORRECT ANSWERS-
Administer the first dose of prescribed antibiotic therapy
A client is brought to the Emergency Department by ambulance in cardiac arrest with
CPR in progress. The client is intubated and receiving 100% O2 per ambu bag. The
nurse determines the client is cyanotic, cold, and diaphoretic. Which assessment is
most important to obtain? - CORRECT ANSWERS-deep tendon reflexes
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a
client develops pontine myselinolysis. Which intervention should the nurse implement
first? - CORRECT ANSWERS-Reorientate client to his room
, A male client with heart failure (HF) calls the clinic and reports he cannot put his shoes
on because they are too tight. Which additional information should the nurse obtain? -
CORRECT ANSWERS-Has his weight changed in the last several days
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? - CORRECT ANSWERS-Apply a high flow
venturi mask
A client with a hx of asthma and bronchitis arrives at the clinic with SOB, productive
cough with thickened tenacious mucous and the inability to walk up a flight of stairs
without experiencing breathlessness. Which action is important for the nurse to instruct
the client about self care? - CORRECT ANSWERS-Increase the daily intake of oral
fluids to to liquefy secretions
A cardiac catherization of a client with heart disease indicates the following blockages
95% LAD 99% proximal circumflex and 95% proximal RCA. The client later asks the
nurse "what does all that mean for me" - CORRECT ANSWERS-3 main arteries have
major blockages with only 1 to 5% of blood flow getting through to the heart muscle
The nurse is caring for a client with a lower left pulmonary abscess which position
should the nurse instruct the client to maintain - CORRECT ANSWERS-left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable
to eat or drink without nausea and vomiting. Which finding should the nurse report to the
healthcare provider - CORRECT ANSWERS-yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a
neuro assessment every 4 hours. which assessment finding warrants immediate
intervention by the nurse? - CORRECT ANSWERS-Increasing Anxiety
The nurse is providing preoperative education for a Jewish client scheduled to receive a
xenograft to promote burn healing. Which info should the nurse provide this client? -
CORRECT ANSWERS-The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requests assistance to
reposition. The wound dehiscences and eviscerates. The nurse moistens an available
sterile dressing and places it over the wound which intervention should the nurse
implement next? - CORRECT ANSWERS-prepare the client to return to the operating
room
A client with carcinoma of the lung is complaining of weakness and has a serum sodium
level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan
of care? - CORRECT ANSWERS-Fluid volume excess
