PN HESI EXIT REAL EXAM 2 TEST BANK WITH
150 EXAM VERIFIED QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (100% CORRECT ANSWERS) HESI
PN EXIT EXAM TEST BANK (BEST FOR EXAM
PREPARATION)
Three days following a surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is the
best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in time.
B. Instruct the client that the stoma will become much smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
- Correct Answer-B. Instruct the client that the stoma will become smaller when the initial
swelling diminishes (Postoperative swelling causes enlargement of the stoma. The nurse can
teach the client that the stoma will become smaller when swelling is diminished (B). This will
help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide
helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides
pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care. (D)
A female client with a nasogastric tube attached to low suction states that she is nauseated.
The nurse assesses that there has been no drainage through the nasogastric tube in the last two
hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use. - Correct Answer-B. Reposition
the client on her side. (The immediate priority is to determine if the tube is functioning
correctly, which would then relieve the client's nausea. The least invasive intervention (B)
should be attempted first, followed by (A and C), unless either of these interventions is
contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D))
1
,A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes
ago, but feels fine now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. - Correct
Answer-C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the
tube.
A male client tells the nurse that he does not know where he is or what year it is. What data
should the nurse document that is most accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time - Correct Answer-D. is disoriented to place and time (The
client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able
to express himself without difficulty (B), and does not demonstrate diminished attention span.
(C).
A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. What
action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CKD. - Correct Answer-A.
Commend the client for selecting a high biologic value protein. (Foods such as eggs and milk (A)
are high biologic proteins which are allowed because they are complete proteins and supply the
essential amino acids that are necessary for growth and cell repair. Orange juice is rich in
potassium and should not be encouraged. The client has made a good diet choice so (D) is not
necessary.)
When assisting an 82 year old client to ambulate, it is important for the nurse to realize that the
center of gravity for an elderly person is the-- - Correct Answer-Upper torso (The center of
gravity for adults is the hips. However, as the person grows older, a stooped posture is common
because of the changes from osteoporosis and normal bone degeneration, and the knees, hips,
and elbows flex. This stooped posture results in the upper torso becoming the center of gravity
for older persons.)
In developing a plan of care for a client with dementia, the nurse should remember that
confusion in the elderly
2
,A. is to be expected, and progresses with age
B. often follows relocation to new surroundings
C. is a result of irreversible brain pathology
D. can be prevented with adequate sleep - Correct Answer-B. often follows relocation to new
surroundings (Relocation (B) often results in confusion among elderly clients-- moving is
stressful for anyone. (A) is stereotypical judgement. Stress in the elderly often manifests itself
as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion.)
A postoperative client will need to perform daily dressing changes after discharge. Which
outcome statement best demonstrates the client's readiness to manage his wound care after
discharge? The client
A. asks relevant questions regarding the dressing change
B. states he will be able to complete the wound care regimen
C. demonstrates the wound care procedure correctly
D. has all the necessary supplies for wound care - Correct Answer-C. demonstrates the wound
care procedure correctly
(A return demonstration of a procedure (C) provides an objective assessment of the client's
ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of
a priority than the the nurse's assessment of the client's ability to complete wound care.)
A client who is 5 '5" tall and weighs 200 pounds is scheduled for surgery the next day. What
question is most important for the nurse to include during the preoperative assessment?
A. What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?"
C. "Do you feel that you are overweight?"
D. "Will a clear liquid diet be okay after surgery?" - Correct Answer-B. "What vitamin and
mineral supplements do you take?"
(Vitamin and mineral supplements (B) may impact medications used during the operative
period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the
surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the
client's preference.)
During the initial morning assessment, a male client denies dysuria but reports that his urine
appears dark amber. Which intervention should the nurse implement?
A. Provide additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C. Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water. - Correct Answer-D. Encourage
additional oral intake of juices and water.
3
, Which intervention is most important for the nurse to implement for a male client who is
experiencing urinary retention?
A. Apply a condom catheter
B. Apply a skin protectant
C. Encourage increased fluid intake
D. Assess for bladder distention - Correct Answer-D. Assess the bladder for distention (Urinary
retention is the inability to void all urine collected in the bladder, which leads to uncomfortable
bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary
incontinence. (C) may worsen the bladder distention.)
A client with acute hemorrhagic anemia is to receive four units of packed RBCs as rapidly as
possible. Which intervention is most important for the nurse to implement?
A. Obtain the pre-transfusion hemoglobin level.
B. Prime the tubing and prepare a blood pump set-up
C. Monitor vital signs q 15 min for the first hour.
D. Ensure the accuracy of the blood type match. - Correct Answer-D. Ensure the accuracy of the
blood type match.
(ALL interventions should be implemented prior to administering blood, but (D) has the highest
priority. Any time blood is administered the nurse should ensure the accuracy of the blood type
match in order to prevent a possible hemolytic reaction.)
A male client being discharged with a prescription for the bronchodilator theophylline tells the
nurse that he understands he is to take three doses of the medication each day. Since, at the
time of discharge, time-released capsules are not available, which dosing schedule should the
nurse advise the client to follow? - Correct Answer-8 AM, 4 PM, and midnight
(Theophylline should be administered on a regular around the clock schedule to provide the
best bronchodilating effect and reduce the potential for adverse effects.)
A client is to receive 10 mEq of KCl diluted in 250 mL of normal saline over 4 hours. At what rate
should the nurse set the client's intravenous infusion pump? - Correct Answer-63 mL/hr
When evaluating a client's plan of care, the nurse determines that a desire outcome was not
achieved. Which action should the nurse implement first?
A. Establish a new nursing diagnosis.
B. Note which actions were not implemented.
C. Add additional nursing orders to the plan.
D. Collaborate with the HCP to make changes. - Correct Answer-B. Note which actions were not
implemented.
(First, the nurse should review which actions in the original plan were not implemented (B) in
order to determine why the original plan did not produce the desired outcome. Appropriate
revisions can then be made, which may include revising the expected outcome, or identifying a
4
150 EXAM VERIFIED QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (100% CORRECT ANSWERS) HESI
PN EXIT EXAM TEST BANK (BEST FOR EXAM
PREPARATION)
Three days following a surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is the
best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in time.
B. Instruct the client that the stoma will become much smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
- Correct Answer-B. Instruct the client that the stoma will become smaller when the initial
swelling diminishes (Postoperative swelling causes enlargement of the stoma. The nurse can
teach the client that the stoma will become smaller when swelling is diminished (B). This will
help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide
helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides
pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care. (D)
A female client with a nasogastric tube attached to low suction states that she is nauseated.
The nurse assesses that there has been no drainage through the nasogastric tube in the last two
hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use. - Correct Answer-B. Reposition
the client on her side. (The immediate priority is to determine if the tube is functioning
correctly, which would then relieve the client's nausea. The least invasive intervention (B)
should be attempted first, followed by (A and C), unless either of these interventions is
contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D))
1
,A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes
ago, but feels fine now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. - Correct
Answer-C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the
tube.
A male client tells the nurse that he does not know where he is or what year it is. What data
should the nurse document that is most accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time - Correct Answer-D. is disoriented to place and time (The
client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able
to express himself without difficulty (B), and does not demonstrate diminished attention span.
(C).
A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. What
action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CKD. - Correct Answer-A.
Commend the client for selecting a high biologic value protein. (Foods such as eggs and milk (A)
are high biologic proteins which are allowed because they are complete proteins and supply the
essential amino acids that are necessary for growth and cell repair. Orange juice is rich in
potassium and should not be encouraged. The client has made a good diet choice so (D) is not
necessary.)
When assisting an 82 year old client to ambulate, it is important for the nurse to realize that the
center of gravity for an elderly person is the-- - Correct Answer-Upper torso (The center of
gravity for adults is the hips. However, as the person grows older, a stooped posture is common
because of the changes from osteoporosis and normal bone degeneration, and the knees, hips,
and elbows flex. This stooped posture results in the upper torso becoming the center of gravity
for older persons.)
In developing a plan of care for a client with dementia, the nurse should remember that
confusion in the elderly
2
,A. is to be expected, and progresses with age
B. often follows relocation to new surroundings
C. is a result of irreversible brain pathology
D. can be prevented with adequate sleep - Correct Answer-B. often follows relocation to new
surroundings (Relocation (B) often results in confusion among elderly clients-- moving is
stressful for anyone. (A) is stereotypical judgement. Stress in the elderly often manifests itself
as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion.)
A postoperative client will need to perform daily dressing changes after discharge. Which
outcome statement best demonstrates the client's readiness to manage his wound care after
discharge? The client
A. asks relevant questions regarding the dressing change
B. states he will be able to complete the wound care regimen
C. demonstrates the wound care procedure correctly
D. has all the necessary supplies for wound care - Correct Answer-C. demonstrates the wound
care procedure correctly
(A return demonstration of a procedure (C) provides an objective assessment of the client's
ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of
a priority than the the nurse's assessment of the client's ability to complete wound care.)
A client who is 5 '5" tall and weighs 200 pounds is scheduled for surgery the next day. What
question is most important for the nurse to include during the preoperative assessment?
A. What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?"
C. "Do you feel that you are overweight?"
D. "Will a clear liquid diet be okay after surgery?" - Correct Answer-B. "What vitamin and
mineral supplements do you take?"
(Vitamin and mineral supplements (B) may impact medications used during the operative
period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the
surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the
client's preference.)
During the initial morning assessment, a male client denies dysuria but reports that his urine
appears dark amber. Which intervention should the nurse implement?
A. Provide additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C. Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water. - Correct Answer-D. Encourage
additional oral intake of juices and water.
3
, Which intervention is most important for the nurse to implement for a male client who is
experiencing urinary retention?
A. Apply a condom catheter
B. Apply a skin protectant
C. Encourage increased fluid intake
D. Assess for bladder distention - Correct Answer-D. Assess the bladder for distention (Urinary
retention is the inability to void all urine collected in the bladder, which leads to uncomfortable
bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary
incontinence. (C) may worsen the bladder distention.)
A client with acute hemorrhagic anemia is to receive four units of packed RBCs as rapidly as
possible. Which intervention is most important for the nurse to implement?
A. Obtain the pre-transfusion hemoglobin level.
B. Prime the tubing and prepare a blood pump set-up
C. Monitor vital signs q 15 min for the first hour.
D. Ensure the accuracy of the blood type match. - Correct Answer-D. Ensure the accuracy of the
blood type match.
(ALL interventions should be implemented prior to administering blood, but (D) has the highest
priority. Any time blood is administered the nurse should ensure the accuracy of the blood type
match in order to prevent a possible hemolytic reaction.)
A male client being discharged with a prescription for the bronchodilator theophylline tells the
nurse that he understands he is to take three doses of the medication each day. Since, at the
time of discharge, time-released capsules are not available, which dosing schedule should the
nurse advise the client to follow? - Correct Answer-8 AM, 4 PM, and midnight
(Theophylline should be administered on a regular around the clock schedule to provide the
best bronchodilating effect and reduce the potential for adverse effects.)
A client is to receive 10 mEq of KCl diluted in 250 mL of normal saline over 4 hours. At what rate
should the nurse set the client's intravenous infusion pump? - Correct Answer-63 mL/hr
When evaluating a client's plan of care, the nurse determines that a desire outcome was not
achieved. Which action should the nurse implement first?
A. Establish a new nursing diagnosis.
B. Note which actions were not implemented.
C. Add additional nursing orders to the plan.
D. Collaborate with the HCP to make changes. - Correct Answer-B. Note which actions were not
implemented.
(First, the nurse should review which actions in the original plan were not implemented (B) in
order to determine why the original plan did not produce the desired outcome. Appropriate
revisions can then be made, which may include revising the expected outcome, or identifying a
4
