SPRING HESI EXIT
1. A Using salt, herbs, and spices The nurse is providing teaching to a client with type 2 diabetes mellitus about important
points for disease and symptom management. Which state-ment by the client indicates understanding
ANSW
will improve the flavor of foods.B Get an eye examination with an ophthalmologist annually.
C Arrange diet schedule around three regular meals a day.
D Inspect feet every month for ingrown nails, cuts, and calluses.: B Get an eyeexamination with an ophthalmologist annually.
2. The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and
perceived stress. In addition toinformation about prescribed medication and administration, which instruc-tion should the
nurse include in the teaching
ANSW
A Center attention on positive upbeat music.B Find outlets for more
social interaction.
C Practice using muscle relaxation techniques.
D Think about reasons the episodes occur.: C Practice using muscle relaxationtechniques.
3. The charge nurse is planning for the shift and has a registered nurse (RN)and a practical nurse (PN) on the team.
Which client should the charge nurseassign to the RN
ANSW
A A 75-year-old client with renal calculi who requires urine straining.
B A 64-year-old client who had a total hip replacement the previous day.C A 30-year-old depressed client who
admits to suicide ideation.
D An adolescent with multiple contusions due to a fall that occurred 2 daysago.: C A 30-year-old depressed client who
admits to suicide ideation.
4. A client with pancreatitis complains of severe epigastric pain, so the nurseadministers a prescribed narcotic analgesic.
Ten minutes later, the client in- sists on sitting up and leaning forward. Which intervention should the nurse implement
ANSW
A Raise head of bed until to a 90 degree angle.
B Position bedside table so the client can lean across it.C Place bed in a reverse
trendelenburg position.
D Encourage rest until the analgesic becomes effective.: B Position bedsidetable so the client can lean across it.
, SPRING HESI EXIT
5. The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and
difficulty walking to the bath- room. The nurse observes right-sided weakness and sluggish enunciation ofspeech. The nurse
should immediately take which action
ANSW
A Maintain elevated positioning of the dependent joints on affected side.
B Keep the bed in the lowest position and initiate seizure and fall precautions.C Place an indwelling urinary catheter and
measure strict intake and output. D Start two large bore IV catheters and review inclusion criteria for IV fibri- nolytic
therapy.: D Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
6. A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has
a tonic-clonic seizure that lasts50 seconds. Following the seizure, the client is lethargic and confused and hiswife tells the nurse
that her husband has never had a seizure before and hasalways been alert and communicative. Which action should the
nurse take
ANSW
A Ask the wife to wait outside the room until the nurse can talk with her.B Keep orienting the client to time and
space until he is less confused. C Notify the emergency response team of the client's seizure.
D Explain the postictal state that usually follows seizures.: D Explain the pos-tictal state that usually follows seizures.
7. The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease.Which
statement(s)made by the clientshould the nurse recognize as needing additional education
ANSW (Select all thatapply.)
A Keep a food diary.
B Eat more canned vegetables.
C Consume foods with saturated fats.D Walk 30 minutes per
day.
E Include oatmeal for breakfast.
F Use a salt substitute.: B Eat more canned vegetables.C Consume foods with saturated
fats.
8. While caring for a toddler receiving oxygen via face mask, the nurse ob- serves that the child's lips and nares are dry and
cracked. Which interventionshould the nurse implement
ANSW
A Use a water soluble lubricant on affected oral and nasal mucosa.
, SPRING HESI EXIT
B Use a topical lidocaine analgesic for cracked lips.
C Ask the mother what she usually uses on the child's lips and nose.
D Apply a petroleum jelly to the child's nose and lips.: A Use a water solublelubricant on affected oral and nasal
mucosa.
9. When assessing a multigravida on the first postpartum day, the nurse findsa moderate amount of lochia rubra, with the
uterus firm, and three finger- breadths above the umbilicus. What action should the nurse implement first
ANSW
A Increase intravenous infusion.
B Massage the uterus to decrease atony.
C Review the hemoglobin to determine hemorrhage.
D Check for a distended bladder.: D Check for a distended bladder.
10. The nurse is caring for a client on the first day postoperative for a de- scending aortic aneurysm repair.Which
assessment finding should the nurseprioritize reporting to the healthcare provider
ANSW
Reference Range
Potassium (Reference Range: 3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
A Serum potassium 4.8 mEg/L (4.8 mmol/L). B Electrocardiogram
ST segment elevation.C Urine output 30 mL/hour.
D Blood pressure 130/80.: B Electrocardiogram ST segment elevation.
11. The healthcare provider prescribes a low-fiber diet for a client with ulcer-ative colitis. Which food selection indicate
to the nurse that the
client understand the prescribed diet
ANSW
A Roast pork, fresh strawberries.
B Baked potato with skin, raw carrots.C Roasted turkey,
canned vegetables.
D Pancakes, whole-grain cereals.: C Roasted turkey, canned vegetables.
12. The psychiatric nurse is caring for clients in an adolescent unit. Whichclient requires the nurse's immediate
attention
ANSW
A An 18-year-old client with antisocial behavior who is being yelled at by otherclients.
B A 17-year-old client diagnosed with bipolar disorder who is pacing aroundthe lobby.
C A 16-year-old client diagnosed with major depression who refuses to par-
, SPRING HESI EXIT
ticipate in a group.
D A 14-year-old client with anorexia nervosa who is refusing to eat the eveningsnack.: A An 18-year-old client with antisocial
behavior who is being yelled at by other clients.
13. A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD) and
peripheral vascular disease (PVD)is being discharged from a skilled nursing facility. Which action is most important for the
nurse to implement
ANSW
A Explain exercise daily regimen.
B Demonstrate specific strengthening exercises.
C Provide typed instructions for healthy diet selection
D Reinforce need for adequate hydration.: C Provide typed instructions forhealthy diet selection
14. A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyoto-my. Which pre-operative nursing action has
the highest priority
ANSW
A Instruct parents regarding care of the incisional area.
B Mark an outline of the "olive-Shaped" mass in the right epigastric area.C Initiate a continuous infusion of IV fluids
per prescription.
D Monitor amount of intake and infant's response to feedings.: C Initiate acontinuous infusion of IV fluids per
prescription.
15. NGN: The client is a 26 yr old female who was in a car accident 6 months ago that killed her mother, husband, and 2
yr old son. She and her father werethe only survivors of the crash. She is seeking care for depression.
Choose the most likely options for the information missing from the statementby selecting from the list of options provided.
The client is exhibiting symptoms of relating to and
.: The client is exhibiting symptoms of PTSD relating to EXPERIENC-ING A LIFE-THREATENING
EVENT and LOSING A LOVE ONE.
16. NGN: After the examination by the physician, the client was diagnosed withdepression and PSTD. The physician wrote
orders for medication that need to be filled. The nurse speaks with the client again to educate her about her diagnose and
medication. How can the nurse build a therapeutic relationshipwith the client
ANSW Select all that apply.
A The nurse can establish a meaningful connection
1. A Using salt, herbs, and spices The nurse is providing teaching to a client with type 2 diabetes mellitus about important
points for disease and symptom management. Which state-ment by the client indicates understanding
ANSW
will improve the flavor of foods.B Get an eye examination with an ophthalmologist annually.
C Arrange diet schedule around three regular meals a day.
D Inspect feet every month for ingrown nails, cuts, and calluses.: B Get an eyeexamination with an ophthalmologist annually.
2. The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and
perceived stress. In addition toinformation about prescribed medication and administration, which instruc-tion should the
nurse include in the teaching
ANSW
A Center attention on positive upbeat music.B Find outlets for more
social interaction.
C Practice using muscle relaxation techniques.
D Think about reasons the episodes occur.: C Practice using muscle relaxationtechniques.
3. The charge nurse is planning for the shift and has a registered nurse (RN)and a practical nurse (PN) on the team.
Which client should the charge nurseassign to the RN
ANSW
A A 75-year-old client with renal calculi who requires urine straining.
B A 64-year-old client who had a total hip replacement the previous day.C A 30-year-old depressed client who
admits to suicide ideation.
D An adolescent with multiple contusions due to a fall that occurred 2 daysago.: C A 30-year-old depressed client who
admits to suicide ideation.
4. A client with pancreatitis complains of severe epigastric pain, so the nurseadministers a prescribed narcotic analgesic.
Ten minutes later, the client in- sists on sitting up and leaning forward. Which intervention should the nurse implement
ANSW
A Raise head of bed until to a 90 degree angle.
B Position bedside table so the client can lean across it.C Place bed in a reverse
trendelenburg position.
D Encourage rest until the analgesic becomes effective.: B Position bedsidetable so the client can lean across it.
, SPRING HESI EXIT
5. The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and
difficulty walking to the bath- room. The nurse observes right-sided weakness and sluggish enunciation ofspeech. The nurse
should immediately take which action
ANSW
A Maintain elevated positioning of the dependent joints on affected side.
B Keep the bed in the lowest position and initiate seizure and fall precautions.C Place an indwelling urinary catheter and
measure strict intake and output. D Start two large bore IV catheters and review inclusion criteria for IV fibri- nolytic
therapy.: D Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
6. A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has
a tonic-clonic seizure that lasts50 seconds. Following the seizure, the client is lethargic and confused and hiswife tells the nurse
that her husband has never had a seizure before and hasalways been alert and communicative. Which action should the
nurse take
ANSW
A Ask the wife to wait outside the room until the nurse can talk with her.B Keep orienting the client to time and
space until he is less confused. C Notify the emergency response team of the client's seizure.
D Explain the postictal state that usually follows seizures.: D Explain the pos-tictal state that usually follows seizures.
7. The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease.Which
statement(s)made by the clientshould the nurse recognize as needing additional education
ANSW (Select all thatapply.)
A Keep a food diary.
B Eat more canned vegetables.
C Consume foods with saturated fats.D Walk 30 minutes per
day.
E Include oatmeal for breakfast.
F Use a salt substitute.: B Eat more canned vegetables.C Consume foods with saturated
fats.
8. While caring for a toddler receiving oxygen via face mask, the nurse ob- serves that the child's lips and nares are dry and
cracked. Which interventionshould the nurse implement
ANSW
A Use a water soluble lubricant on affected oral and nasal mucosa.
, SPRING HESI EXIT
B Use a topical lidocaine analgesic for cracked lips.
C Ask the mother what she usually uses on the child's lips and nose.
D Apply a petroleum jelly to the child's nose and lips.: A Use a water solublelubricant on affected oral and nasal
mucosa.
9. When assessing a multigravida on the first postpartum day, the nurse findsa moderate amount of lochia rubra, with the
uterus firm, and three finger- breadths above the umbilicus. What action should the nurse implement first
ANSW
A Increase intravenous infusion.
B Massage the uterus to decrease atony.
C Review the hemoglobin to determine hemorrhage.
D Check for a distended bladder.: D Check for a distended bladder.
10. The nurse is caring for a client on the first day postoperative for a de- scending aortic aneurysm repair.Which
assessment finding should the nurseprioritize reporting to the healthcare provider
ANSW
Reference Range
Potassium (Reference Range: 3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
A Serum potassium 4.8 mEg/L (4.8 mmol/L). B Electrocardiogram
ST segment elevation.C Urine output 30 mL/hour.
D Blood pressure 130/80.: B Electrocardiogram ST segment elevation.
11. The healthcare provider prescribes a low-fiber diet for a client with ulcer-ative colitis. Which food selection indicate
to the nurse that the
client understand the prescribed diet
ANSW
A Roast pork, fresh strawberries.
B Baked potato with skin, raw carrots.C Roasted turkey,
canned vegetables.
D Pancakes, whole-grain cereals.: C Roasted turkey, canned vegetables.
12. The psychiatric nurse is caring for clients in an adolescent unit. Whichclient requires the nurse's immediate
attention
ANSW
A An 18-year-old client with antisocial behavior who is being yelled at by otherclients.
B A 17-year-old client diagnosed with bipolar disorder who is pacing aroundthe lobby.
C A 16-year-old client diagnosed with major depression who refuses to par-
, SPRING HESI EXIT
ticipate in a group.
D A 14-year-old client with anorexia nervosa who is refusing to eat the eveningsnack.: A An 18-year-old client with antisocial
behavior who is being yelled at by other clients.
13. A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD) and
peripheral vascular disease (PVD)is being discharged from a skilled nursing facility. Which action is most important for the
nurse to implement
ANSW
A Explain exercise daily regimen.
B Demonstrate specific strengthening exercises.
C Provide typed instructions for healthy diet selection
D Reinforce need for adequate hydration.: C Provide typed instructions forhealthy diet selection
14. A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyoto-my. Which pre-operative nursing action has
the highest priority
ANSW
A Instruct parents regarding care of the incisional area.
B Mark an outline of the "olive-Shaped" mass in the right epigastric area.C Initiate a continuous infusion of IV fluids
per prescription.
D Monitor amount of intake and infant's response to feedings.: C Initiate acontinuous infusion of IV fluids per
prescription.
15. NGN: The client is a 26 yr old female who was in a car accident 6 months ago that killed her mother, husband, and 2
yr old son. She and her father werethe only survivors of the crash. She is seeking care for depression.
Choose the most likely options for the information missing from the statementby selecting from the list of options provided.
The client is exhibiting symptoms of relating to and
.: The client is exhibiting symptoms of PTSD relating to EXPERIENC-ING A LIFE-THREATENING
EVENT and LOSING A LOVE ONE.
16. NGN: After the examination by the physician, the client was diagnosed withdepression and PSTD. The physician wrote
orders for medication that need to be filled. The nurse speaks with the client again to educate her about her diagnose and
medication. How can the nurse build a therapeutic relationshipwith the client
ANSW Select all that apply.
A The nurse can establish a meaningful connection
