Hesi Rn Exit Exam V2 Full 160 Questions And Answers

1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa." D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." - D 154. A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation? A) Abnormal breath sounds B) Cyanosis of the lips C) Increasing pulse rate D) Pulse oximeter reading of 92% - C 149. A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not want it." The nurse's best response is A) "This is a common occurrence after birth, but you will come to accept the baby." B) "Many women have postpartum blues and need some time to love the baby." C) "What a beautiful baby! Her eyes are just like yours." D) "You seem upset; tell me what the pregnancy and birth were like for you." - D 150. Which of the following times is a depressed client at highest risk for attempting suicide? A) Immediately after admission, during one-to-one observation B) 7 to 14 days after initiation of antidepressant medication and psychotherapy C) Following an angry outburst with family D) When the client is removed from the security room - B 151. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time? A) What are you taking for pain and does it provide total relief? B) What does the skin on the testicles look and feel like? C) Do you have any questions about your care? D) Did you know a consequence of epididymitis is infertility? - B 152. A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of Digoxin to this client? A) Assess the apical pulse, counting for a full 60 seconds B) Take a radial pulse, counting for a full 60 seconds C) Use the pulse reading from the electronic blood pressure device D) Check for a pulse deficit - A 153. A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem? A) Chest pain B) Pallor C) Inspiratory crackles D) Heart murmur - C 156. A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse should recognize that the client may be developing which complication? A) Acute compartment syndrome B) Thromboemolitic complications C) Fatty embolism D) Osteomyelitis - A 155. Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis? A) Active and passive range of motion exercises twice a day B) Every 4 hours incentive spirometer C) Chest physiotherapy twice a day D) Repositioning every 2 hours around the clock - C 157. The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the mother supports the presence of this problem? A) When I put my finger in the left hand the baby doesn't respond with a grasp. B) My baby doesn't seem to follow when I shake toys in front of the face. C) When it thundered loudly last night the baby didn't even jump. D) When I put the baby in a back lying position that's how I find the baby. - D 158. Which statements by the client would indicate to the nurse an understanding of the issues with end stage renal disease? A) I have to go at intervals for epoetin (Procrit) injections at the health department. B) I know I have a high risk of clot formation since my blood is thick from too many red cells. C) I expect to have periods of little water with voiding and then sometimes to have a lot of water. D) My bones will be stronger with this disease since I will have higher calcium than normal. - A 159. The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action? A) Lower extremity pitting edema B) Rales C) Jugular vein distension D) Weakness in left arm - D 132. What assessment data should the nurse obtain next? A) Status of the eyes and the tongue B) Description of play activity C) History of fluid intake D) Dietary patterns - A 2. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary - B 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) - D 110. A client has returned to the unit following a renal biopsy. Which of the 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 - C 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 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." - C 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) Akathesia C) Brady dysknesia D) Tardive dyskinesia - D 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 - B 106. The nurse is caring for a 4 year-old 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 - D 105. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic reponse to the drug? A) Bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time - C 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." - C 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 - A 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) Slows stomach emptying time D) Decreases production of hydrochloric acid - B 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 - A 99. What finding signifies that children have attained the stage of concrete operations (Piaget)? A) Explores the environment with the use of sight and movement B) Thinks in mental images or word pictures C) Makes the moral judgement that "stealing is wrong" D) Reasons that homework is time-consuming yet necessary - C 98. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first? A) Notify the health care provider B) Administer the PRN dose of Albuterol C) Apply oxygen at 2 liters per nasal cannula D) Repeat the peak flow reading in 30 minutes - B 97. A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? A) Cheese crackers B) Peanut butter sandwich C) Potato chips D) Vanilla cookies - C 96. The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? A) Antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside within the first 24 hours - C 95. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? A) Drowsiness, lethargy, and inactivity B) Dry mouth, nasal congestion, and blurred vision C) Rash, blood dyscrasias, severe depression D) Hyperglycemia, weight gain, and edema - C 94. The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized? A) Call the Poison Control Center once the situation is identified B) Empty the child's mouth in any case of possible poisoning C) Have the child move minimally if a toxic substance was inhaled D) Do not induce vomiting if the poison is a hydrocarbon - B 93. An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice? A) Bologna sandwich, pudding, milk B) Frankfurter, baked potato, milk C) Chicken strips, corn on the cob, milk D) Grilled cheese sandwich, apple, milk - C 92. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? A) Complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) Continue to take prophylactic doses for at least 5 years after the diagnosis - B 91. The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing - C 90. An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the following allergies. Of these allergies which one should all health care personnel be aware of? A) Shellfish B) Molds C) Balloons D) Perfumed soap - C 89. The nurse is planning discharge for a 90 year-old client with musculoskeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls? A) Place nightlight in the bedroom B) Wear eyeglasses at all times C) Install grab bars in the bathroom D) Teach muscle strengthening exercises - A 87. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings - B 88. The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period? A) Estrogen replacement therapy B) 10% less than ideal body weight C) Hypersensitivity to heparin D) History of hepatitis - A 86. Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice - C 85. The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied A) When it is 1/3 to 1/2 full B) Prior to meals C) After each fecal elimination D) At the same time each day - A 84. A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? A) The client lost 2 pounds in 24 hours B) The client's potassium level is 4 mEq/liter. C) The client's urine output was 1500 cc in 5 hours D) The client is to receive another dose of Lasix at 10 PM - C 83. A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these? A) Negative room ventilation B) Face mask with sheild C) Particulate respirator mask D) Airborne precautions - C 82. A client is recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? A) Tetany and paresthesia B) Mild stridor and hoarseness C) Irritability and insomnia D) Headache and nausea - A 81. A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? A) I got back from Central America a few weeks ago. B) I had the best raw oysters last week. C) I have many different sex partners. D) I had a blood transfusion 15 years ago. - D 80. A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on this data, what is the first nursing action? A) Review other lab data B) Notify the health care provider C) Administer oxygen D) Calm the client - C 79. The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? A) Storing the packed red cells in the medicine refrigerator while starting IV B) Slow the rate of infusion if the client develops fever or chills C) Limit the infusion time of each of the unit to a maximum of 4 hours D) Assess vital signs every 15 minutes throughout the entire infusion - C 78. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? A) Solid foods are introduced 1 at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake D) Solid foods should be mixed with formula in a bottle - A 77. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicate a potential hazard for this test? A) Reflex incontinence B) Allergic to shellfish C) Claustrophobia D) Hypertension - B 76. When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the nurse would suggest for the parents to give sips of which substance? A) Tea B) Water C) Milk D) Soda - B 75. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair - D 74. The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication? A) Nebulized treatments for home care B) Adding a spacer device to the MDI canister C) Asking a family member to assist the client with the MDI D) Request a visiting nurse to follow the client at home - B 73. A 2 year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water - B 72. The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate? A) The parents' name and telephone number B) The currency of the immunization and allergy history of the child C) The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance D) The affected child's age and weight - D 71. Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required? A) pH below 7.3 B) Potassium of 5.0 C) HCT of 60 D) Pa O2 of 79% - C 51. A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boil the tap water for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled "lead free" to mix the formula - C 3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered - B 53. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from... A) a tissue bank." B) a pig." C) my thigh." D) synthetic skin." - C 54. The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? A) Risk for dehydration B) Ineffective airway clearance C) Altered nutrition D) Risk for injury - B 55. A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return - D 52. A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The most appropriate intervention for this client is A) Position client in upright position while eating B) Place client on a clear liquid diet C) Tilt head back to facilitate swallowing reflex D) Offer finger foods such as crackers or pretzels - A 4. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? A) An infant with intermittent bulging anterior fontanel between crying episodes B) A toddler with severe deep abrasions over 98% of the body C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture D) A school-age child with singed eyebrows and hair on the arms - B 5. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to A) Change whichever item is incorrect to the correct information B) Use the bracelet and admission form until a replacement is supplied C) Notify the admissions office and wait to apply the bracelet D) Make a corrected identification bracelet for the client - C 6. The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? A) Leave the order for the oncoming staff to follow-up B) Contact the charge nurse for an interpretation