Hesi Exit Exam
A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of
the solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter
numeric value only.)
200ml . 25 ml of full strength feeding mixed with 25ml of water provided 50ml of half strength.
25ml × 8 hours= 200ml
An elderly male client is experiencing urinary incontinence. What is the best initial nursing
action?
3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous
antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids
to enter his body once he is cleansed for prayer. What action should the nurse implement?
Reschedule administration of the antibiotic until after he completes his prayers
UAP using a hand sanitzers that is alcohol for 2 minutes
tell that hand sanitizer use is less > 2min
5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled
procedure. The child weighs 44 pounds. How many mg of the medication should the nurse
administer
Answer: 800 Rationale: First, convert the child's weight to kg: 44 pounds divided by
,2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg
6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal
bleeding spurts rather than trickles from the vagina. The uterine fundus is firm and the client's
vital signs are pulse 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure,
104/68 mmHg. What action should the nurse take next?
Compare current vital signs with previous vital signs
A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded
in his eye. Which action should the school nurse take?
Have the parent take the child for emergency help
Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech
bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse
identifies a nursing diagnosis of "Altered thought processes, secondary to" what condition?
Postpartum psychosis
The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual cramps" for a
25-year-old female client. Which self-care activity should the nurse emphasize in the client's
teaching plan?
,Regular aerobic exercise.
Psych/Alcohol/Tylenol overdose antidote
Give Mucomyst
Medical Surgical/Laxative abuses
Patient -taking Milk of Magnesium
Spiritual/Documentation
Native American - Allow pt's family to stay in the room
Leadership- Interpreter informed consent
Pt should sign the consent
Geriatrics/Emergency Rib fractures fall
Pulmonary embolism
, A client diagnosed with major depression is being allowed a weekend pass from the psychiatric
unit. Which instruction should the nurse provide to the client's family?
Involve the client in usual at home activities
Upon assessment, the nurse discovers that a postpartum client has persistent red lochia.
Which of the following does this assessment finding suggest to the nurse?
Coagulation disorders
The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is
drained. What action should the nurse complete first?
Assess vital signs.
After administering a medication through a nasogastric tube connected to suction, what action
should the nurse take first?
Clamp the tube
The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.;
A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of
the solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter
numeric value only.)
200ml . 25 ml of full strength feeding mixed with 25ml of water provided 50ml of half strength.
25ml × 8 hours= 200ml
An elderly male client is experiencing urinary incontinence. What is the best initial nursing
action?
3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous
antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids
to enter his body once he is cleansed for prayer. What action should the nurse implement?
Reschedule administration of the antibiotic until after he completes his prayers
UAP using a hand sanitzers that is alcohol for 2 minutes
tell that hand sanitizer use is less > 2min
5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled
procedure. The child weighs 44 pounds. How many mg of the medication should the nurse
administer
Answer: 800 Rationale: First, convert the child's weight to kg: 44 pounds divided by
,2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg
6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal
bleeding spurts rather than trickles from the vagina. The uterine fundus is firm and the client's
vital signs are pulse 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure,
104/68 mmHg. What action should the nurse take next?
Compare current vital signs with previous vital signs
A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded
in his eye. Which action should the school nurse take?
Have the parent take the child for emergency help
Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech
bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse
identifies a nursing diagnosis of "Altered thought processes, secondary to" what condition?
Postpartum psychosis
The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual cramps" for a
25-year-old female client. Which self-care activity should the nurse emphasize in the client's
teaching plan?
,Regular aerobic exercise.
Psych/Alcohol/Tylenol overdose antidote
Give Mucomyst
Medical Surgical/Laxative abuses
Patient -taking Milk of Magnesium
Spiritual/Documentation
Native American - Allow pt's family to stay in the room
Leadership- Interpreter informed consent
Pt should sign the consent
Geriatrics/Emergency Rib fractures fall
Pulmonary embolism
, A client diagnosed with major depression is being allowed a weekend pass from the psychiatric
unit. Which instruction should the nurse provide to the client's family?
Involve the client in usual at home activities
Upon assessment, the nurse discovers that a postpartum client has persistent red lochia.
Which of the following does this assessment finding suggest to the nurse?
Coagulation disorders
The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is
drained. What action should the nurse complete first?
Assess vital signs.
After administering a medication through a nasogastric tube connected to suction, what action
should the nurse take first?
Clamp the tube
The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.;
