HESI EXIT V2 LATEST UPDATE 2024/25
(CLINICAL RELIABLE) COMPLETE QUESTIONS
WITH VERIFIED ANSWERS DOWNLOAD
PERFECT SCORE GRADED A+
100.The nurse is caring for a 17-month-old with acetaminophen poisoning. Which of the
following lab reports should the nurse review first?
A) Protime (PT) and partial thromboplastin time (PTT)
B) Red blood cell and white blood cell counts
C) Blood urea nitrogen and creatinine clearance
D) Liver enzymes(AST and ALT) - Correct Answers-D) Liver enzymes(AST and ALT)
101. The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis
and mild dehydration. In addition to oral rehydration fluids, the diet should include
A) Formula or breast milk
B) Broth and tea
C) Rice cereal and apple juice
D) Gelatin and ginger ale - Correct Answers-A) Formula or breast milk
102. The nurse instructs the client taking dexamethasone (Decadron) to take it with food
or milk. What is the physiological basis for this instruction?
A) Retards pepsin production
B) Stimulates hydrochloric acid production
C) Slow Stomach emptying time
D) Decreases production of hydrochloric acid - Correct Answers-B) Stimulates hydrochloric acid
production
103. The nurse is planning care for a 3 month-old infant immediately postoperative
following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to
A) Assess for abdominal distention
B) Maintain infant in an upright position
C) Begin formula feedings when infant is alert
D) Pump the shunt to assess for proper function - Correct Answers-A) Assess for abdominal distention
,104. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming
every time the mother gets ready to leave the hospital room. What is the
Best response by the nurse?
A) "I think you or your partner needs to stay with the child while in the hospital."
B) "Oh, that behavior will stop in a few days."
C) "Keep in mind that for the age this is a normal response to being in the hospital."
D) "You might want to "sneak out" of the room once the child falls asleep." - Correct Answers-C)
"Keep in mind that for the age this is a normal response to being in the hospital."
105. When caring for a client receiving warfarin sodium (Coumadin),which lab test
would the nurse monitor to determine therapeutic response to the drug? A) Bleeding time
B) Coagulation time
C) Prothrombin time
D) Partial thromboplastin time - Correct Answers-C) Prothrombin time
106. The nurse is caring for a 4 year-old for 2 hours after tonsillectomy and adenoidectomy.
Which of the following assessments must be reported immediately? A) Vomiting of dark emesis
B) Complaints of throat pain
C) Apical heart rate of 110
D) Increased restlessness - Correct Answers-D) Increased restlessness
107. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays
show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The
appropriate
response by the nurse should be which of these statements?
A) "The injury is expected to heal quickly because of thin
periosteum."
B) "In some instances the result is a retarded bone growth."
C) "Bone growth is stimulated in the affected leg."
D) "This type of injury shows more rapid union than that of younger children." - Correct Answers-B)
"In some instances the result is a retarded bone growth."
108. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care.
During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth.
The nurse
,recognizes this assessment finding as what?
A) Dystonia
B) Akathisia
C) Brady dyskinesia
D) Tardive dyskinesia - Correct Answers-D) Tardive dyskinesia
109. During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to
the nurse because a flat pink birthmark on the baby's forehead and
the eyelid has not gone away. What is an appropriate response by the nurse?
A) "Mongolian spots are a normal finding in dark-skinned children."
B) "Port wine stains are often associated with other malformations."
C) "Telangiectatic nevi are normal and will disappear as the baby grows."
D) "The child is too young for consideration of surgical removal of these at this time." - Correct
Answers-C) "Telangiectatic nevi are normal and will disappear as the baby grows."
110. A client has returned to the unit following a renal biopsy. Which ofthe following
nursing interventions is appropriate?
A) Ambulate the client 4 hours after procedure
B) Maintain client on NPO status for 24 hours
C) Monitor vital signs
D) Change dressing every 8 hours - Correct Answers-C) Monitor vital signs
111. A client has been admitted with a fractured femur and has been placed in skeletal
traction. Which of the following nursing interventions should receive priority?
A) Maintaining proper body alignment
B) Frequent neurovascular assessments of the affected leg
C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to
assist the client with movement in bed - Correct Answers-B) Frequent neurovascular assessments of
the affected leg
112. The nurse is teaching a client newly diagnosed with asthma how to use the metered dose
inhaler (MDI). The client asks when they will know the canister is empty. The best
response is
A) Drop the canister in water to observe floating
B) Estimate how many doses are usually in the canister
, C) Count the number of doses asthma inhaler is used
D) Shake the canister to detect any fluid movement - Correct Answers-A) Drop the canister in water
to observe floating
113. While teaching the family of a child who will take phenytoin (Dilantin)regularly for
seizure control, it is most important for the nurse to teach them about which of the following actions?
A) Maintain good oral hygiene and dental care
B) Omit medication if the child is seizure free
C) Administer acetaminophen to promote sleep
D) Serve a diet that is high in iron - Correct Answers-A) Maintain good oral hygiene and dental care
114. A 7 month pregnant woman is admitted with complaints of painlessvaginal bleeding
over several hours. The nurse should prepare the client for an immediate
A) Non stress test
B) Abdominal ultrasound
C) Pelvic exam
D) X-ray of abdomen - Correct Answers-B) Abdominal ultrasound
115. The nurse is assessing a 17 year-old female client with bulimia. Which of the
following laboratory reports would the nurse anticipate?
A) Increased serum glucose
B) Decreased albumin
C) Decreased potassium
D) Increased sodium retention - Correct Answers-C) Decreased potassium
116. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting,abdominal cramps and halo
vision. Which of the following laboratory results should the nurse analyze first?
A) Potassium levels
B) Blood pH
C) Magnesium levels
D) Blood urea nitrogen - Correct Answers-A) Potassium levels
117. The nurse caring for a 9 year-old child with a fractured femur is told that a medication error
occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is
a priority at this time?
A) Risk for fluid volume deficit related to morphine overdose
(CLINICAL RELIABLE) COMPLETE QUESTIONS
WITH VERIFIED ANSWERS DOWNLOAD
PERFECT SCORE GRADED A+
100.The nurse is caring for a 17-month-old with acetaminophen poisoning. Which of the
following lab reports should the nurse review first?
A) Protime (PT) and partial thromboplastin time (PTT)
B) Red blood cell and white blood cell counts
C) Blood urea nitrogen and creatinine clearance
D) Liver enzymes(AST and ALT) - Correct Answers-D) Liver enzymes(AST and ALT)
101. The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis
and mild dehydration. In addition to oral rehydration fluids, the diet should include
A) Formula or breast milk
B) Broth and tea
C) Rice cereal and apple juice
D) Gelatin and ginger ale - Correct Answers-A) Formula or breast milk
102. The nurse instructs the client taking dexamethasone (Decadron) to take it with food
or milk. What is the physiological basis for this instruction?
A) Retards pepsin production
B) Stimulates hydrochloric acid production
C) Slow Stomach emptying time
D) Decreases production of hydrochloric acid - Correct Answers-B) Stimulates hydrochloric acid
production
103. The nurse is planning care for a 3 month-old infant immediately postoperative
following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to
A) Assess for abdominal distention
B) Maintain infant in an upright position
C) Begin formula feedings when infant is alert
D) Pump the shunt to assess for proper function - Correct Answers-A) Assess for abdominal distention
,104. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming
every time the mother gets ready to leave the hospital room. What is the
Best response by the nurse?
A) "I think you or your partner needs to stay with the child while in the hospital."
B) "Oh, that behavior will stop in a few days."
C) "Keep in mind that for the age this is a normal response to being in the hospital."
D) "You might want to "sneak out" of the room once the child falls asleep." - Correct Answers-C)
"Keep in mind that for the age this is a normal response to being in the hospital."
105. When caring for a client receiving warfarin sodium (Coumadin),which lab test
would the nurse monitor to determine therapeutic response to the drug? A) Bleeding time
B) Coagulation time
C) Prothrombin time
D) Partial thromboplastin time - Correct Answers-C) Prothrombin time
106. The nurse is caring for a 4 year-old for 2 hours after tonsillectomy and adenoidectomy.
Which of the following assessments must be reported immediately? A) Vomiting of dark emesis
B) Complaints of throat pain
C) Apical heart rate of 110
D) Increased restlessness - Correct Answers-D) Increased restlessness
107. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays
show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The
appropriate
response by the nurse should be which of these statements?
A) "The injury is expected to heal quickly because of thin
periosteum."
B) "In some instances the result is a retarded bone growth."
C) "Bone growth is stimulated in the affected leg."
D) "This type of injury shows more rapid union than that of younger children." - Correct Answers-B)
"In some instances the result is a retarded bone growth."
108. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care.
During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth.
The nurse
,recognizes this assessment finding as what?
A) Dystonia
B) Akathisia
C) Brady dyskinesia
D) Tardive dyskinesia - Correct Answers-D) Tardive dyskinesia
109. During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to
the nurse because a flat pink birthmark on the baby's forehead and
the eyelid has not gone away. What is an appropriate response by the nurse?
A) "Mongolian spots are a normal finding in dark-skinned children."
B) "Port wine stains are often associated with other malformations."
C) "Telangiectatic nevi are normal and will disappear as the baby grows."
D) "The child is too young for consideration of surgical removal of these at this time." - Correct
Answers-C) "Telangiectatic nevi are normal and will disappear as the baby grows."
110. A client has returned to the unit following a renal biopsy. Which ofthe following
nursing interventions is appropriate?
A) Ambulate the client 4 hours after procedure
B) Maintain client on NPO status for 24 hours
C) Monitor vital signs
D) Change dressing every 8 hours - Correct Answers-C) Monitor vital signs
111. A client has been admitted with a fractured femur and has been placed in skeletal
traction. Which of the following nursing interventions should receive priority?
A) Maintaining proper body alignment
B) Frequent neurovascular assessments of the affected leg
C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to
assist the client with movement in bed - Correct Answers-B) Frequent neurovascular assessments of
the affected leg
112. The nurse is teaching a client newly diagnosed with asthma how to use the metered dose
inhaler (MDI). The client asks when they will know the canister is empty. The best
response is
A) Drop the canister in water to observe floating
B) Estimate how many doses are usually in the canister
, C) Count the number of doses asthma inhaler is used
D) Shake the canister to detect any fluid movement - Correct Answers-A) Drop the canister in water
to observe floating
113. While teaching the family of a child who will take phenytoin (Dilantin)regularly for
seizure control, it is most important for the nurse to teach them about which of the following actions?
A) Maintain good oral hygiene and dental care
B) Omit medication if the child is seizure free
C) Administer acetaminophen to promote sleep
D) Serve a diet that is high in iron - Correct Answers-A) Maintain good oral hygiene and dental care
114. A 7 month pregnant woman is admitted with complaints of painlessvaginal bleeding
over several hours. The nurse should prepare the client for an immediate
A) Non stress test
B) Abdominal ultrasound
C) Pelvic exam
D) X-ray of abdomen - Correct Answers-B) Abdominal ultrasound
115. The nurse is assessing a 17 year-old female client with bulimia. Which of the
following laboratory reports would the nurse anticipate?
A) Increased serum glucose
B) Decreased albumin
C) Decreased potassium
D) Increased sodium retention - Correct Answers-C) Decreased potassium
116. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting,abdominal cramps and halo
vision. Which of the following laboratory results should the nurse analyze first?
A) Potassium levels
B) Blood pH
C) Magnesium levels
D) Blood urea nitrogen - Correct Answers-A) Potassium levels
117. The nurse caring for a 9 year-old child with a fractured femur is told that a medication error
occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is
a priority at this time?
A) Risk for fluid volume deficit related to morphine overdose
