EXIT HESI PN UPDATED EVALUATION ANSWERS
AND QUESTIONS SET A+
✔✔The nurse is assisting a father to change the diaper of his 2-day-old infant. The
father notices several bluish-black pigmented areas on the infant's buttocks and asks
the nurse, "What did you do to my baby?" Which response is best for the nurse to
provide?
A."What makes you think we did anything to your baby?"
B."Are you or any of your blood relatives of Asian descent?"
C."Those are stork bites and will go away in about 2 years."
D."Those are Mongolian spots and will gradually fade in 1 or 2 years." - ✔✔D
Mongolian spots (D) are areas of bluish-black or gray-blue pigmentation seen primarily
on the dorsal area and buttocks of infants of Asian or African decent or dark-skinned
babies. (A) is a defensive answer. Although Mongolian spots occur more frequently in
those of Asian and African decent, (B) does not respond to the father's concern.
Telangiectatic nevi, frequently referred to as stork bites (C), appear reddish-purple or
red and are usually on the face or head and neck area.
✔✔The nurse is planning a community teaching program regarding the use of folic acid
to prevent neural tube birth defects. Which community group is likely to benefit most
from this program?
A.Parents of children with spina bifida
B.High school girls in a health class
C.Individuals interested in having children
D.Postpartum women attending a baby care class - ✔✔C
Folic acid is needed early in pregnancy to prevent neural tube defects; the group most
likely to be considering pregnancy is (C). Parents with children who already have a
neural tube defect such as spina bifida (A) are not as invested in the content as (C).
High school age students (B) may have interest in the topic but as a group are less
likely to anticipate the likelihood that problems could occur in their lives than (C). (D)
may be interested if planning future pregnancies, but have higher learning priorities
during the postpartum period.
,✔✔A client who is on the outpatient surgical unit is preparing for discharge after a
myringotomy with placement of ventilating tubes. Which response by the client indicates
that further teaching is necessary?
A."I will avoid coughing, sneezing, and forceful nose blowing."
B."Swimming can begin on the tenth postoperative day."
C."Any mild discomfort can be managed with acetaminophen."
D."Drainage from my ears is expected after the surgery." - ✔✔B
The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure
and drain fluid collection from the middle ear. The tube's patency allows air and water to
enter the middle ear, so the client should be reeducated if the client swims (B) or allows
water to enter the external ear. (A, C, and D) reflect correct responses.
✔✔A male client with arterial peripheral vascular disease (PVD) complains of pain in his
feet. Which instruction should the nurse give to the UAP to relieve the client's pain
quickly?
A.Help the client dangle his legs.
B.Apply compression stockings.
C.Assist with passive leg exercises.
D.Ambulate three times a day. - ✔✔A
The client who has arterial PVD may benefit from dependent positioning, and this can
be achieved with bedside dangling (A), which will promote gravitation of blood to the
feet, improve blood flow, and relieve pain. (B) is indicated for venous insufficiency (C)
and indicated for bed rest. Ambulation (D) is indicated to facilitate collateral circulation
and may improve long-term complaints of pain.
✔✔Which situation demonstrates proper application of client confidentiality
requirements for the Health Insurance Portability and Accountability Act (HIPAA)?
A.Clients' names are not used while they are in a public waiting room.
B.Nurses should not recommend any community self-help groups by specific name,
such as Alcoholics Anonymous.
C.Clients must pick up their filled prescriptions from a pharmacy in person with a photo
identification card.
D.Old medical records are kept in a locked file cabinet in the department. - ✔✔D
Past medical records must be "secured" and "reasonably protected" from inadvertent
viewing (D). A locked room or file cabinet can serve this purpose, and when any
protected health information (PHI) is discarded, it must be shredded. A person's name
only (without their diagnosis or treatment) is not considered confidential or PHI (A).
Nurses may suggest categories of community resources, with examples, such as
Alcoholics Anonymous (B), but cannot market a specific program in which they have a
financial interest. Others can pick up a client's filled prescriptions (C).
, ✔✔Prior to administering an oral suspension, which intervention is most important for
the nurse to implement?
A.Assess the client's ability to swallow liquids.
B.Obtain applesauce in which to mix the medication.
C.Determine the client's food likes and dislikes.
D.Auscultate the client's breath sounds. - ✔✔A
An oral suspension is a liquid, so the nurse needs to assess the client's ability to
swallow liquids (A) to ensure that the client will not choke. If the client has difficulty
swallowing liquids, a thickening substance may be used (B). If a food product is used to
thicken the liquid, (C) would be beneficial. (D) may also be warranted, but only if the
client is at risk for aspiration, determined by (A).
✔✔A client with schizophrenia tells the nurse, "The world is coming to an end. All the
violence in the Middle East is soon going to destroy the entire world!" How should the
nurse respond?
A."Let's play some dominoes for a few minutes."
B."I don't think the violence means the world is ending."
C."The news makes you have upsetting thoughts."
D."Listening to the news seems to be frightening you." - ✔✔D
A client's delusional statements are best addressed by identifying the feeling associated
with the delusion (D). Distraction (A) may be helpful but ignores the feelings that the
client is experiencing. Delusional clients often argue with statements that contradict their
belief system (B). The client is unlikely to understand the relationship between the news
and the thoughts experienced (C).
✔✔A client with glomerulonephritis is scheduled for a creatinine clearance test to
determine the need for dialysis. Which information should the nurse provide the client
prior to the test?
A.Failure to collect all urine specimens during the period of the study will invalidate the
test.
B.Blood is collected to measure the amount of creatinine and determine the glomerular
filtration rate (GFR).
C.Dialysis is started when the GFR is lower than 5 mL/min.
D.Discard the first voiding, and record the time and amount of urine of each voiding for
24 hours. - ✔✔A
Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear
serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test,
so all urine should be collected during the period of the study or the results are
inaccurate (A). As renal function decreases, the creatinine level will decrease in the
urine (B). Dialysis is usually started when the GFR is 12 mL/min (C). There is no need
to record the frequency and amount of each voiding (D) during the time span of urine
collection.
AND QUESTIONS SET A+
✔✔The nurse is assisting a father to change the diaper of his 2-day-old infant. The
father notices several bluish-black pigmented areas on the infant's buttocks and asks
the nurse, "What did you do to my baby?" Which response is best for the nurse to
provide?
A."What makes you think we did anything to your baby?"
B."Are you or any of your blood relatives of Asian descent?"
C."Those are stork bites and will go away in about 2 years."
D."Those are Mongolian spots and will gradually fade in 1 or 2 years." - ✔✔D
Mongolian spots (D) are areas of bluish-black or gray-blue pigmentation seen primarily
on the dorsal area and buttocks of infants of Asian or African decent or dark-skinned
babies. (A) is a defensive answer. Although Mongolian spots occur more frequently in
those of Asian and African decent, (B) does not respond to the father's concern.
Telangiectatic nevi, frequently referred to as stork bites (C), appear reddish-purple or
red and are usually on the face or head and neck area.
✔✔The nurse is planning a community teaching program regarding the use of folic acid
to prevent neural tube birth defects. Which community group is likely to benefit most
from this program?
A.Parents of children with spina bifida
B.High school girls in a health class
C.Individuals interested in having children
D.Postpartum women attending a baby care class - ✔✔C
Folic acid is needed early in pregnancy to prevent neural tube defects; the group most
likely to be considering pregnancy is (C). Parents with children who already have a
neural tube defect such as spina bifida (A) are not as invested in the content as (C).
High school age students (B) may have interest in the topic but as a group are less
likely to anticipate the likelihood that problems could occur in their lives than (C). (D)
may be interested if planning future pregnancies, but have higher learning priorities
during the postpartum period.
,✔✔A client who is on the outpatient surgical unit is preparing for discharge after a
myringotomy with placement of ventilating tubes. Which response by the client indicates
that further teaching is necessary?
A."I will avoid coughing, sneezing, and forceful nose blowing."
B."Swimming can begin on the tenth postoperative day."
C."Any mild discomfort can be managed with acetaminophen."
D."Drainage from my ears is expected after the surgery." - ✔✔B
The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure
and drain fluid collection from the middle ear. The tube's patency allows air and water to
enter the middle ear, so the client should be reeducated if the client swims (B) or allows
water to enter the external ear. (A, C, and D) reflect correct responses.
✔✔A male client with arterial peripheral vascular disease (PVD) complains of pain in his
feet. Which instruction should the nurse give to the UAP to relieve the client's pain
quickly?
A.Help the client dangle his legs.
B.Apply compression stockings.
C.Assist with passive leg exercises.
D.Ambulate three times a day. - ✔✔A
The client who has arterial PVD may benefit from dependent positioning, and this can
be achieved with bedside dangling (A), which will promote gravitation of blood to the
feet, improve blood flow, and relieve pain. (B) is indicated for venous insufficiency (C)
and indicated for bed rest. Ambulation (D) is indicated to facilitate collateral circulation
and may improve long-term complaints of pain.
✔✔Which situation demonstrates proper application of client confidentiality
requirements for the Health Insurance Portability and Accountability Act (HIPAA)?
A.Clients' names are not used while they are in a public waiting room.
B.Nurses should not recommend any community self-help groups by specific name,
such as Alcoholics Anonymous.
C.Clients must pick up their filled prescriptions from a pharmacy in person with a photo
identification card.
D.Old medical records are kept in a locked file cabinet in the department. - ✔✔D
Past medical records must be "secured" and "reasonably protected" from inadvertent
viewing (D). A locked room or file cabinet can serve this purpose, and when any
protected health information (PHI) is discarded, it must be shredded. A person's name
only (without their diagnosis or treatment) is not considered confidential or PHI (A).
Nurses may suggest categories of community resources, with examples, such as
Alcoholics Anonymous (B), but cannot market a specific program in which they have a
financial interest. Others can pick up a client's filled prescriptions (C).
, ✔✔Prior to administering an oral suspension, which intervention is most important for
the nurse to implement?
A.Assess the client's ability to swallow liquids.
B.Obtain applesauce in which to mix the medication.
C.Determine the client's food likes and dislikes.
D.Auscultate the client's breath sounds. - ✔✔A
An oral suspension is a liquid, so the nurse needs to assess the client's ability to
swallow liquids (A) to ensure that the client will not choke. If the client has difficulty
swallowing liquids, a thickening substance may be used (B). If a food product is used to
thicken the liquid, (C) would be beneficial. (D) may also be warranted, but only if the
client is at risk for aspiration, determined by (A).
✔✔A client with schizophrenia tells the nurse, "The world is coming to an end. All the
violence in the Middle East is soon going to destroy the entire world!" How should the
nurse respond?
A."Let's play some dominoes for a few minutes."
B."I don't think the violence means the world is ending."
C."The news makes you have upsetting thoughts."
D."Listening to the news seems to be frightening you." - ✔✔D
A client's delusional statements are best addressed by identifying the feeling associated
with the delusion (D). Distraction (A) may be helpful but ignores the feelings that the
client is experiencing. Delusional clients often argue with statements that contradict their
belief system (B). The client is unlikely to understand the relationship between the news
and the thoughts experienced (C).
✔✔A client with glomerulonephritis is scheduled for a creatinine clearance test to
determine the need for dialysis. Which information should the nurse provide the client
prior to the test?
A.Failure to collect all urine specimens during the period of the study will invalidate the
test.
B.Blood is collected to measure the amount of creatinine and determine the glomerular
filtration rate (GFR).
C.Dialysis is started when the GFR is lower than 5 mL/min.
D.Discard the first voiding, and record the time and amount of urine of each voiding for
24 hours. - ✔✔A
Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear
serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test,
so all urine should be collected during the period of the study or the results are
inaccurate (A). As renal function decreases, the creatinine level will decrease in the
urine (B). Dialysis is usually started when the GFR is 12 mL/min (C). There is no need
to record the frequency and amount of each voiding (D) during the time span of urine
collection.
