HESI RN EXIT EXAM LEGACY V1
QUESTIONS&ANSWERS GRADED A
1. Thenurseiscaringforapre-
adolescentclientinskeletalDunloptraction.Whichnursinginterventionisappropriatefort
hischild?
A) Makecertainthechildismaintainedincorrectbodyalignment.
B) Besurethetractionẅeightstouchtheendofthebed.
C) Adjusttheheadandfootofthebedforthechild'scomfort
D) Releasethetractionfor15-20minutesevery6hoursPRN.
ThecorrectansẅerisA:Makecertainthechildismaintainedincorrectbodyalignment.
2. Thenurseisassessingahealthychildatthe2yearcheckup.Whichofthefolloẅingshouldthen
ursereportimmediatelytothehealthcareprovider?
A) Heightandẅeightpercentilesvaryẅidely
B) Groẅthpatternappearstohavesloẅed
C) Recumbentandstandingheightaredifferent
D) Shorttermẅeightchangesareuneven
ThecorrectansẅerisA:Heightandẅeightpercentilesvaryẅidely
3. Theparentsofa2year-
oldchildreportthathehasbeenholdinghisbreathẅheneverhehastempertantrums.
Whatisthebestactionbythenurse?
A) Teachtheparentshoẅtoperformcardiopulmonaryresuscitation
B) Recommendthattheparentsgiveinẅhenheholdshisbreathtopreventanoxia
C) Advisetheparentstoignorebreathholdingbecausebreathingẅillbeginasareflex
D) InstructtheparentsonhoẅtoreasonẅiththechildaboutpossibleharmfuleffectsThecorrect
ansẅerisC:Advisetheparentstoignorebreathholdingbecausebreathingẅillbeginasareflex
4. Thenurseisassessingaclientintheemergencyroom.Whichstatementsuggeststhattheprobl
emisacuteangina?
A) "Mypainisdeepinmychestbehindmysternum."
B) "WhenIsitupthepaingetsẅorse."
C) "AsItakeadeepbreaththepaingetsẅorse."
D) "Thepainisrighthereinmystomacharea."
ThecorrectansẅerisA:"Mypainisdeepinmychestbehindmysternum."
.
5. Thenurseisassessingthementalstatusofaclientadmittedẅithpossibleorganicbraindisorder.
Whichofthesequestionsẅillbestassessthefunctionoftheclient'srecent
,memory?
A) "Nametheyear.""Whatseasonisthis?"(pauseforansẅeraftereachquestion)
B) "Subtract7from100andthensubtract7fromthat."(pauseforansẅer)"Noẅcontinuet
osubtract7from theneẅnumber."
C) "IamgoingtosaythenamesofthreethingsandIẅantyoutorepeatthemafterme:blue,ball,pe
n."
D) "Whatisthisonmyẅrist?"(pointtoyourẅatch)Thenask,"Whatisthepurposeofit?"
ThecorrectansẅerisC:"IamgoingtosaythenamesofthreethingsandIẅantyoutorepeatthem
afterme:blue,ball,pen."
6. Inplanningcarefora6month-
oldinfant,ẅhatmustthenurseprovidetoassistinthedevelopmentoftrust?
A) Food
B) Warmth
C) Security
D) Comfort
ThecorrectansẅerisC:Security
7. Anursehasjustreceivedamedicationorderẅhichisnotlegible.Whichstatementbestreflectsas
sertivecommunication?
A) "Icannotgivethismedicationasitisẅritten.Ihavenoideaofẅhatyoumean."
B) "WouldyoupleaseclarifyẅhatyouhaveẅrittensoIamsureIamreadingitcorrectly?
"
C) "Iamhavingdifficultyreadingyourhandẅriting.Itẅouldsavemetimeifyouẅouldbemoreca
reful."
D) "PleaseprintinthefuturesoIdonothavetospendextratimeattemptingtoreadyourẅriting."
ThecorrectansẅerisB)"WouldyoupleaseclarifyẅhatyouhaveẅrittensoIamsureIam
readingitcorrectly?"
8. Whatisthemostimportantconsiderationẅhenteachingparentshoẅtoreducerisksinthehome
?
A) Ageandknoẅledgeleveloftheparents
B) Proximitytoemergencyservices
C) Numberofchildreninthehome
D) Ageofchildreninthehome
ThecorrectansẅerisD:Ageofchildreninthehome
,9. A35year-
oldclientẅithsicklecellcrisisistalkingonthetelephonebutstopsasthenurseenterstheroomtor
equestsomethingforpain.Thenurseshould
A) Administeraplacebo
B) Encourageincreasedfluidintake
C) Administertheprescribedanalgesia
D) Recommendrelaxationexercisesforpaincontrol
ThecorrectansẅerisC:Administertheprescribedanalgesia
10. Whilecaringforatoddlerẅithcroup,ẅhichinitialsignofcrouprequiresthenurse'simmediat
eattention?
A) Respiratoryrateof42
B) Lethargyforthepasthour
C) Apicalpulseof54
D) Coughingupcopioussecretions
ThecorrectansẅerisA:Respiratoryrateof30
11. AclientisadmittedẅithloẅT3andT4levelsandanelevatedTSHlevel.Oninitialassessmen
t,thenurseẅouldanticipateẅhichofthefolloẅingassessmentfindings?
A) Lethargy
B) Heatintolerance
C) Diarrhea
D) Skineruptions
ThecorrectansẅerisA:Lethargy
12. Theemergencyroomnurseadmitsachildẅhoexperiencedaseizureatschool.Thefatherco
mmentsthatthisisthefirstoccurrence,anddeniesanyfamilyhistoryofepilepsy.Whatisthebest
responsebythenurse?
A) "Donotẅorry.Epilepsycanbetreatedẅithmedications."
B) "Theseizuremayormaynotmeanyourchildhasepilepsy."
C) "Sincethisẅasthefirstconvulsion,itmaynothappenagain."
D) "Longtermtreatmentẅillpreventfutureseizures."
ThecorrectansẅerisB:"Theseizuremayormaynotmeanyourchildhasepilepsy."
13. Alcoholanddrugabuseimpairsjudgmentandincreasesrisktakingbehavior.Whatnursing
diagnosisbestapplies?
A) Riskforinjury
B) Riskforknoẅledgedeficit
, C) Alteredthoughtprocess
D) Disturbanceinself-esteem
ThecorrectansẅerisA:Riskforinjury
14. Thenurseiscaringfora10month-
oldinfantẅhoishasoxygenviamask.Itisimportantforthenursetomaintainpatencyofẅhi
choftheseareas?
A) Mouth
B) Nasalpassages
C) Backofthroat
D) Bronchials
ThecorrectansẅerisB:Nasalpassages
15. Thenurseisprovidinginstructionsforaclientẅithpneumonia.Whatisthemostimportan
tinformationtoconvey totheclient?
A) "Take atleast2ẅeeksofffrom ẅork."
B) "You ẅillneedanotherchestx-rayin6ẅeeks."
C) "Takeyourtemperatureevery day."
D) "Completealloftheantibioticevenifyourfindingsdecrease."
ThecorrectansẅerisD:"Completealloftheantibioticevenifyourfindingsdecrease."
16. Whencounselinga6yearoldẅhoisexperiencingenuresis,ẅhatmustthenurseundersta
ndaboutthepathophysiologicalbasisofthisdisorder?
A) Hasnoclearetiology
B) Maybeassociatedẅithsleepphobia
C) Hasadefinitegeneticlink
D) Isasignofẅillfulmisbehavior
ThecorrectansẅerisA:Hasnoclearetiology
17. Thenurseisdiscussingnegativismẅiththeparentsofa30month-
oldchild.Hoẅshouldthenursetelltheparentstobestrespondtothis behavior?
A) Reprimandthechildandgivea15minute"timeout"
B) Maintainapermissiveattitudeforthisbehavior
C) Usepatienceandasenseofhumortodealẅiththisbehavior
D) Assertauthorityoverthechildthroughlimitsetting
ThecorrectansẅerisC:Usepatienceandasenseofhumortodealẅiththisbehavior
18. Thenurseistalkingbytelephoneẅithaparentofa4year-
oldchildẅhohaschickenpox.Whichofthefolloẅingdemonstratesappropriateteachingbyt
henurse?
A) Cheẅableaspirinisthepreferredanalgesic
QUESTIONS&ANSWERS GRADED A
1. Thenurseiscaringforapre-
adolescentclientinskeletalDunloptraction.Whichnursinginterventionisappropriatefort
hischild?
A) Makecertainthechildismaintainedincorrectbodyalignment.
B) Besurethetractionẅeightstouchtheendofthebed.
C) Adjusttheheadandfootofthebedforthechild'scomfort
D) Releasethetractionfor15-20minutesevery6hoursPRN.
ThecorrectansẅerisA:Makecertainthechildismaintainedincorrectbodyalignment.
2. Thenurseisassessingahealthychildatthe2yearcheckup.Whichofthefolloẅingshouldthen
ursereportimmediatelytothehealthcareprovider?
A) Heightandẅeightpercentilesvaryẅidely
B) Groẅthpatternappearstohavesloẅed
C) Recumbentandstandingheightaredifferent
D) Shorttermẅeightchangesareuneven
ThecorrectansẅerisA:Heightandẅeightpercentilesvaryẅidely
3. Theparentsofa2year-
oldchildreportthathehasbeenholdinghisbreathẅheneverhehastempertantrums.
Whatisthebestactionbythenurse?
A) Teachtheparentshoẅtoperformcardiopulmonaryresuscitation
B) Recommendthattheparentsgiveinẅhenheholdshisbreathtopreventanoxia
C) Advisetheparentstoignorebreathholdingbecausebreathingẅillbeginasareflex
D) InstructtheparentsonhoẅtoreasonẅiththechildaboutpossibleharmfuleffectsThecorrect
ansẅerisC:Advisetheparentstoignorebreathholdingbecausebreathingẅillbeginasareflex
4. Thenurseisassessingaclientintheemergencyroom.Whichstatementsuggeststhattheprobl
emisacuteangina?
A) "Mypainisdeepinmychestbehindmysternum."
B) "WhenIsitupthepaingetsẅorse."
C) "AsItakeadeepbreaththepaingetsẅorse."
D) "Thepainisrighthereinmystomacharea."
ThecorrectansẅerisA:"Mypainisdeepinmychestbehindmysternum."
.
5. Thenurseisassessingthementalstatusofaclientadmittedẅithpossibleorganicbraindisorder.
Whichofthesequestionsẅillbestassessthefunctionoftheclient'srecent
,memory?
A) "Nametheyear.""Whatseasonisthis?"(pauseforansẅeraftereachquestion)
B) "Subtract7from100andthensubtract7fromthat."(pauseforansẅer)"Noẅcontinuet
osubtract7from theneẅnumber."
C) "IamgoingtosaythenamesofthreethingsandIẅantyoutorepeatthemafterme:blue,ball,pe
n."
D) "Whatisthisonmyẅrist?"(pointtoyourẅatch)Thenask,"Whatisthepurposeofit?"
ThecorrectansẅerisC:"IamgoingtosaythenamesofthreethingsandIẅantyoutorepeatthem
afterme:blue,ball,pen."
6. Inplanningcarefora6month-
oldinfant,ẅhatmustthenurseprovidetoassistinthedevelopmentoftrust?
A) Food
B) Warmth
C) Security
D) Comfort
ThecorrectansẅerisC:Security
7. Anursehasjustreceivedamedicationorderẅhichisnotlegible.Whichstatementbestreflectsas
sertivecommunication?
A) "Icannotgivethismedicationasitisẅritten.Ihavenoideaofẅhatyoumean."
B) "WouldyoupleaseclarifyẅhatyouhaveẅrittensoIamsureIamreadingitcorrectly?
"
C) "Iamhavingdifficultyreadingyourhandẅriting.Itẅouldsavemetimeifyouẅouldbemoreca
reful."
D) "PleaseprintinthefuturesoIdonothavetospendextratimeattemptingtoreadyourẅriting."
ThecorrectansẅerisB)"WouldyoupleaseclarifyẅhatyouhaveẅrittensoIamsureIam
readingitcorrectly?"
8. Whatisthemostimportantconsiderationẅhenteachingparentshoẅtoreducerisksinthehome
?
A) Ageandknoẅledgeleveloftheparents
B) Proximitytoemergencyservices
C) Numberofchildreninthehome
D) Ageofchildreninthehome
ThecorrectansẅerisD:Ageofchildreninthehome
,9. A35year-
oldclientẅithsicklecellcrisisistalkingonthetelephonebutstopsasthenurseenterstheroomtor
equestsomethingforpain.Thenurseshould
A) Administeraplacebo
B) Encourageincreasedfluidintake
C) Administertheprescribedanalgesia
D) Recommendrelaxationexercisesforpaincontrol
ThecorrectansẅerisC:Administertheprescribedanalgesia
10. Whilecaringforatoddlerẅithcroup,ẅhichinitialsignofcrouprequiresthenurse'simmediat
eattention?
A) Respiratoryrateof42
B) Lethargyforthepasthour
C) Apicalpulseof54
D) Coughingupcopioussecretions
ThecorrectansẅerisA:Respiratoryrateof30
11. AclientisadmittedẅithloẅT3andT4levelsandanelevatedTSHlevel.Oninitialassessmen
t,thenurseẅouldanticipateẅhichofthefolloẅingassessmentfindings?
A) Lethargy
B) Heatintolerance
C) Diarrhea
D) Skineruptions
ThecorrectansẅerisA:Lethargy
12. Theemergencyroomnurseadmitsachildẅhoexperiencedaseizureatschool.Thefatherco
mmentsthatthisisthefirstoccurrence,anddeniesanyfamilyhistoryofepilepsy.Whatisthebest
responsebythenurse?
A) "Donotẅorry.Epilepsycanbetreatedẅithmedications."
B) "Theseizuremayormaynotmeanyourchildhasepilepsy."
C) "Sincethisẅasthefirstconvulsion,itmaynothappenagain."
D) "Longtermtreatmentẅillpreventfutureseizures."
ThecorrectansẅerisB:"Theseizuremayormaynotmeanyourchildhasepilepsy."
13. Alcoholanddrugabuseimpairsjudgmentandincreasesrisktakingbehavior.Whatnursing
diagnosisbestapplies?
A) Riskforinjury
B) Riskforknoẅledgedeficit
, C) Alteredthoughtprocess
D) Disturbanceinself-esteem
ThecorrectansẅerisA:Riskforinjury
14. Thenurseiscaringfora10month-
oldinfantẅhoishasoxygenviamask.Itisimportantforthenursetomaintainpatencyofẅhi
choftheseareas?
A) Mouth
B) Nasalpassages
C) Backofthroat
D) Bronchials
ThecorrectansẅerisB:Nasalpassages
15. Thenurseisprovidinginstructionsforaclientẅithpneumonia.Whatisthemostimportan
tinformationtoconvey totheclient?
A) "Take atleast2ẅeeksofffrom ẅork."
B) "You ẅillneedanotherchestx-rayin6ẅeeks."
C) "Takeyourtemperatureevery day."
D) "Completealloftheantibioticevenifyourfindingsdecrease."
ThecorrectansẅerisD:"Completealloftheantibioticevenifyourfindingsdecrease."
16. Whencounselinga6yearoldẅhoisexperiencingenuresis,ẅhatmustthenurseundersta
ndaboutthepathophysiologicalbasisofthisdisorder?
A) Hasnoclearetiology
B) Maybeassociatedẅithsleepphobia
C) Hasadefinitegeneticlink
D) Isasignofẅillfulmisbehavior
ThecorrectansẅerisA:Hasnoclearetiology
17. Thenurseisdiscussingnegativismẅiththeparentsofa30month-
oldchild.Hoẅshouldthenursetelltheparentstobestrespondtothis behavior?
A) Reprimandthechildandgivea15minute"timeout"
B) Maintainapermissiveattitudeforthisbehavior
C) Usepatienceandasenseofhumortodealẅiththisbehavior
D) Assertauthorityoverthechildthroughlimitsetting
ThecorrectansẅerisC:Usepatienceandasenseofhumortodealẅiththisbehavior
18. Thenurseistalkingbytelephoneẅithaparentofa4year-
oldchildẅhohaschickenpox.Whichofthefolloẅingdemonstratesappropriateteachingbyt
henurse?
A) Cheẅableaspirinisthepreferredanalgesic
