HESI 799 RN EXIT EXAM (NIGHTINGALE COLLEGE) SPRING-SUMMER ACTUAL TEST
QUESTIONS WITH ACCURATE SOLUTIONS
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?
a. Remind the client that it is also important to switch to decaffeinated coffee and tea.
b. Suggest that the client also plan to eat frequent small meals to reduce discomfort
c. Review with the client the need to avoid foods that are rich in milk and cream.
d. Reinforce this teaching by asking the client to list a dairy food that he might select.
Review with the client the need to avoid foods that are rich in milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be
avoided.
A male client with hypertension, who received new antihypertensive prescriptions at his
last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is
158/106 and he admits that he has not been taking the prescribed medication because the
drugs make him "feel bad". In explaining the need for hypertension control, the nurse
should stress that an elevated BP places the client at risk for which pathophysiological
condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
Stroke secondary to hemorrhage
,Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted
client who has a seizure disorder. The client is supine and the UAP is placing soft pillows
along the side rails. What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
c. Assume responsibility for placing the pillows while the UAP completes another task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying position.
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest
because the use of pillows could result in suffocation and would need to be removed at the
onset of the seizure. The nurse can delegate paddling the side rails to the UAP
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the past 12 days. Which assessment finding requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
,Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is
known to increase the risk of suicidal thinking in adolescents and young adults with major
depressive disorder. B, C and D are side effects
A 60-year-old female client with a positive family history of ovarian cancer has developed
an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau
(Pap) smear results are negative. What information should the nurse include in the client's
teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed.
Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer should be
evaluated carefully
A client who recently underwent a tracheostomy is being prepared for discharge to home.
Which instructions is most important for the nurse to include in the discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
, d. Demonstrate how to clean tracheostomy site.
Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is
critical.
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen
reservoir bag does not deflate completely during inspiration and the client's respiratory rate
is 14 breaths / minute. What action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which
client alarm should the nurse investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
QUESTIONS WITH ACCURATE SOLUTIONS
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?
a. Remind the client that it is also important to switch to decaffeinated coffee and tea.
b. Suggest that the client also plan to eat frequent small meals to reduce discomfort
c. Review with the client the need to avoid foods that are rich in milk and cream.
d. Reinforce this teaching by asking the client to list a dairy food that he might select.
Review with the client the need to avoid foods that are rich in milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be
avoided.
A male client with hypertension, who received new antihypertensive prescriptions at his
last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is
158/106 and he admits that he has not been taking the prescribed medication because the
drugs make him "feel bad". In explaining the need for hypertension control, the nurse
should stress that an elevated BP places the client at risk for which pathophysiological
condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
Stroke secondary to hemorrhage
,Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted
client who has a seizure disorder. The client is supine and the UAP is placing soft pillows
along the side rails. What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
c. Assume responsibility for placing the pillows while the UAP completes another task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying position.
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest
because the use of pillows could result in suffocation and would need to be removed at the
onset of the seizure. The nurse can delegate paddling the side rails to the UAP
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the past 12 days. Which assessment finding requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
,Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is
known to increase the risk of suicidal thinking in adolescents and young adults with major
depressive disorder. B, C and D are side effects
A 60-year-old female client with a positive family history of ovarian cancer has developed
an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau
(Pap) smear results are negative. What information should the nurse include in the client's
teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed.
Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer should be
evaluated carefully
A client who recently underwent a tracheostomy is being prepared for discharge to home.
Which instructions is most important for the nurse to include in the discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
, d. Demonstrate how to clean tracheostomy site.
Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is
critical.
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen
reservoir bag does not deflate completely during inspiration and the client's respiratory rate
is 14 breaths / minute. What action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which
client alarm should the nurse investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
