PN HESI EXIT Exam A PRACTICE Questions
with Approved Answers Guaranteed
Excellent Scores
A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the
baby sucks for a few minutes?" Which information should the nurse provide?
A.This feeling occurs during feeding with a breast infection.
B.This sensation occurs as breast milk moves to the nipple.
C.The baby does not have good latch-on.
D.The infant is not positioned correctly. - Answer -B
When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a
tingling sensation in their nipples (B) when let-down occurs. (A, C, and D) provide inaccurate information.
A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic
complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the
nurse implement first?
A.Check the client's blood pressure.
B.Teach her to elevate her feet when sitting.
C.Obtain a 24-hour diet history to evaluate for the intake of salty foods.
D.Assess the fetal heart rate. - Answer -A
The blood pressure (A) should be assessed first. Preeclampsia is a multisystem disorder, and women
older than 35 years and have chronic hypertension are at increased risk. Classic signs include headache,
visual changes, edema, recent rapid weight gain, and elevated blood pressure. (B, C, and D) can be done
if the blood pressure is normal.
A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the
nurse implement?
A.Teach the client testicular self-examination (TSE).
B.Assess for the presence of blood in the urine.
C.Ask about scrotal pain or blood in the semen.
,D.Inquire about a history of kidney stones. - Answer -C
Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent
sexually transmitted disease (STD), or an indwelling urethral urinary catheter causing pain on ejaculation,
scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of
other symptoms (C). Although all men should practice TSE, the client's symptoms are suggestive of an
inflammatory syndrome rather than testicular cancer (A). Although hematuria (B) is associated with renal
disease or calculi (D), the client's pain is associated with ejaculate, not urine.
A 77-year-old female client states that she has never been so large around the waist and that she has
frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which
information should the nurse provide to this client?
A.As women age, they often become rounder in the middle because they do not exercise properly.
B.Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur
with aging.
C.With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause
constipation.
D.Because there is no evidence of a diseased colon, there is no need to worry about abdominal size -
Answer -C
With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist.
Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the
primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and
constipation are age-related changes. (D) dismisses the client's concerns and does not help her
understand the changes that she is experiencing.
A child is having a generalized tonic-clonic seizure. Which action should the nurse take?
A.Move objects out of the child's immediate area.
B.Quickly slip soft restraints on the child's wrists.
C.Insert a padded tongue blade between the teeth.
D.Place in the recovery position before going for help. - Answer -A
The first priority during a seizure is to provide a safe environment, so the nurse should clear the area (A)
to reduce the risk of trauma. The child should not be restrained (B) because this may cause more
trauma. Objects should not be placed in the child's mouth (C) because it may pose a choking hazard.
Although (D) should be implemented after the seizure, the nurse should not leave the child during a
seizure to get help.
,A child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of breakfast foods at
a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her
child?
A.French toast sticks and orange juice
B.Sausage egg muffin and grape juice
C.Canadian bacon slices and hot chocolate
D.Toasted oat cereal and low-fat milk - Answer -D
A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-
sugar diet. Based on these guidelines, the best breakfast choice is (D). (A) is high in fat and sugar. (B and
C) are high in fat and sodium.
A client has been on a mechanical ventilator for several days. What should the nurse use to document
and record this client's respirations?
A.The respiratory settings on the ventilator
B.Only the client's spontaneous respirations
C.The ventilator-assisted respirations minus the client's independent breaths
D.The ventilator setting for respiratory rate and the client-initiated respirations - Answer -D
The nurse should count the client's respirations, and document both the respiratory rate set by the
ventilator and the client's independent respiratory rate (D). Never rely strictly on (A). Although the
client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to
record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory
picture of the client (B and C).
A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP
reports to the nurse that the client has had three loose foul-smelling stools this morning. Which
intervention is most important for the nurse to implement?
A.Perform a digital evaluation for fecal impaction.
B.Administer a PRN dose of psyllium (Metamucil).
C.Obtain a stool specimen for culture and sensitivity.
D.Instruct the UAP to obtain incontinent pads for the client. - Answer -C
Long-term use of levofloxacin (Levaquin) can cause foul-smelling diarrhea because of Clostridium difficile
infection or associated colitis, so it is most important to obtain a stool specimen (C). Impaction is
, unlikely, so (A) is of less priority and may not be necessary. (B) is a bulk-forming agent that may be used
for constipation or diarrhea. Treatment of the diarrhea and client comfort (D) are important
interventions but of less priority than determining the cause of the client's diarrhea.
A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to
be exhibiting?
A.Hyperexcitability of reflexes
B.Hyperextension of the head and back
C.Inability to flex the chin to the chest
D.Lateral facial paralysis - Answer -C
Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to
flex the neck and place the chin to the chest (C). Although (A, B, and D) may occur in meningitis, (A)
describes exaggerated spinal nerve reflex responses, (B) describes opisthotonus, and (D) may be related
to cranial nerve pathology of the trigeminal nerve.
A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and
sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this
happened." Which statement by the nurse is most therapeutic?
A."It sounds like you're feeling very sad."
B."Tell me more about how you're feeling."
C."How often do you have crying spells?"
D."Do you want to talk about these feelings?" - Answer -B
It is most therapeutic to ask an open-ended question and encourage the client to explore his or her
feelings (B). (A) is a leading response, and the client may not be feeling sad. (C and D) are close-ended
questions that do not facilitate communication.
A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse
provide?
A.Save the next urine sample.
B.Restrict oral fluid intake.
C.Strain all voided urine.
D.Reduce physical activity. - Answer -A
with Approved Answers Guaranteed
Excellent Scores
A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the
baby sucks for a few minutes?" Which information should the nurse provide?
A.This feeling occurs during feeding with a breast infection.
B.This sensation occurs as breast milk moves to the nipple.
C.The baby does not have good latch-on.
D.The infant is not positioned correctly. - Answer -B
When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a
tingling sensation in their nipples (B) when let-down occurs. (A, C, and D) provide inaccurate information.
A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic
complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the
nurse implement first?
A.Check the client's blood pressure.
B.Teach her to elevate her feet when sitting.
C.Obtain a 24-hour diet history to evaluate for the intake of salty foods.
D.Assess the fetal heart rate. - Answer -A
The blood pressure (A) should be assessed first. Preeclampsia is a multisystem disorder, and women
older than 35 years and have chronic hypertension are at increased risk. Classic signs include headache,
visual changes, edema, recent rapid weight gain, and elevated blood pressure. (B, C, and D) can be done
if the blood pressure is normal.
A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the
nurse implement?
A.Teach the client testicular self-examination (TSE).
B.Assess for the presence of blood in the urine.
C.Ask about scrotal pain or blood in the semen.
,D.Inquire about a history of kidney stones. - Answer -C
Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent
sexually transmitted disease (STD), or an indwelling urethral urinary catheter causing pain on ejaculation,
scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of
other symptoms (C). Although all men should practice TSE, the client's symptoms are suggestive of an
inflammatory syndrome rather than testicular cancer (A). Although hematuria (B) is associated with renal
disease or calculi (D), the client's pain is associated with ejaculate, not urine.
A 77-year-old female client states that she has never been so large around the waist and that she has
frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which
information should the nurse provide to this client?
A.As women age, they often become rounder in the middle because they do not exercise properly.
B.Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur
with aging.
C.With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause
constipation.
D.Because there is no evidence of a diseased colon, there is no need to worry about abdominal size -
Answer -C
With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist.
Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the
primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and
constipation are age-related changes. (D) dismisses the client's concerns and does not help her
understand the changes that she is experiencing.
A child is having a generalized tonic-clonic seizure. Which action should the nurse take?
A.Move objects out of the child's immediate area.
B.Quickly slip soft restraints on the child's wrists.
C.Insert a padded tongue blade between the teeth.
D.Place in the recovery position before going for help. - Answer -A
The first priority during a seizure is to provide a safe environment, so the nurse should clear the area (A)
to reduce the risk of trauma. The child should not be restrained (B) because this may cause more
trauma. Objects should not be placed in the child's mouth (C) because it may pose a choking hazard.
Although (D) should be implemented after the seizure, the nurse should not leave the child during a
seizure to get help.
,A child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of breakfast foods at
a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her
child?
A.French toast sticks and orange juice
B.Sausage egg muffin and grape juice
C.Canadian bacon slices and hot chocolate
D.Toasted oat cereal and low-fat milk - Answer -D
A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-
sugar diet. Based on these guidelines, the best breakfast choice is (D). (A) is high in fat and sugar. (B and
C) are high in fat and sodium.
A client has been on a mechanical ventilator for several days. What should the nurse use to document
and record this client's respirations?
A.The respiratory settings on the ventilator
B.Only the client's spontaneous respirations
C.The ventilator-assisted respirations minus the client's independent breaths
D.The ventilator setting for respiratory rate and the client-initiated respirations - Answer -D
The nurse should count the client's respirations, and document both the respiratory rate set by the
ventilator and the client's independent respiratory rate (D). Never rely strictly on (A). Although the
client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to
record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory
picture of the client (B and C).
A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP
reports to the nurse that the client has had three loose foul-smelling stools this morning. Which
intervention is most important for the nurse to implement?
A.Perform a digital evaluation for fecal impaction.
B.Administer a PRN dose of psyllium (Metamucil).
C.Obtain a stool specimen for culture and sensitivity.
D.Instruct the UAP to obtain incontinent pads for the client. - Answer -C
Long-term use of levofloxacin (Levaquin) can cause foul-smelling diarrhea because of Clostridium difficile
infection or associated colitis, so it is most important to obtain a stool specimen (C). Impaction is
, unlikely, so (A) is of less priority and may not be necessary. (B) is a bulk-forming agent that may be used
for constipation or diarrhea. Treatment of the diarrhea and client comfort (D) are important
interventions but of less priority than determining the cause of the client's diarrhea.
A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to
be exhibiting?
A.Hyperexcitability of reflexes
B.Hyperextension of the head and back
C.Inability to flex the chin to the chest
D.Lateral facial paralysis - Answer -C
Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to
flex the neck and place the chin to the chest (C). Although (A, B, and D) may occur in meningitis, (A)
describes exaggerated spinal nerve reflex responses, (B) describes opisthotonus, and (D) may be related
to cranial nerve pathology of the trigeminal nerve.
A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and
sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this
happened." Which statement by the nurse is most therapeutic?
A."It sounds like you're feeling very sad."
B."Tell me more about how you're feeling."
C."How often do you have crying spells?"
D."Do you want to talk about these feelings?" - Answer -B
It is most therapeutic to ask an open-ended question and encourage the client to explore his or her
feelings (B). (A) is a leading response, and the client may not be feeling sad. (C and D) are close-ended
questions that do not facilitate communication.
A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse
provide?
A.Save the next urine sample.
B.Restrict oral fluid intake.
C.Strain all voided urine.
D.Reduce physical activity. - Answer -A
