lOMoAR cPSD| 19693624 lOMoAR cPSD| 19693624
lOMoAR cPSD| 19693624
4. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated
and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing
HESI RN EXIT EXAM V2 2023 (+900 score!)|A GRADED intervention should the nurse implement?
A. Instruct the mother to change the child’s diaper more often.
1. The school nurse is preparing a presentation for a elementary school teachers to inform teachers to inform B. Encourage the mother to apply lotion with each diaper change.
them about when a child should be referred to the school clinic for further follow-up. The teachers should be
instructed to report which situations to the school nurse? (Select all that apply) C. Ask the mother to decrease the infant’s intake of fruits for 24 hours.
A. Refuses to complete written homework assignments. D. Tell the mother to cleanse with soap and water at each diaper change.
B. Thirst and frequent requests for bathroom breaks. ANS: A
C. Bruises on both knees after the weekend.
D. Sunburn with blisters on the face, arms, and hands. 5. The nurse is having difficulty palpating a client’s posterior tibial pulse while the client is lying in a supine
position?
E. Shaking that changes the child’s hand writing.
A. Extend the client’s arm fully while supporting the elbow and attempt to repalpate.
ANS: B D E
B. Apply less pressure when palpating over the middle of the dorsum of the foot.
C. Use an ultrasound stethoscope place behind and below the medial bone.
2. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to
treat bladder cancer, which instruction is most important for the nurse to include in the client’s discharge D. Help the client to a prone position with the knee slightly flexed and palpate again.
teaching plan? ANS: D
A. Report any signs of cloudy urine output.
B. Frequent empty bladder to avoid distention. 6. The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which
C. Follow instructions for self-care toileting. outcome indicates that the program was effective?
D. Seek counselling for body image. A. Average client scores improved on specific risk factor knowledge tests.
ANS: A B. Only 30% of clients did not attend self-management education sessions.
C. More that 50% of at-risk clients were diagnosed early in the disease process.
3. A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic. Which D. Client who developed disease complications promptly received rehabilitation.
assessment finding should prompt the nurse to administer a PRN dose of naloxone? ANS: D
A. Unresponsive to verbal or tactile stimuli.
B. Respiratory rate of 12 breath/minute. 7. A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin
C. Statements about visual hallucinations. are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client
complains of pain at the right groin insertion site. What action should the nurse implement?
D. Complaints of increasing flank pain.
A. Stimulate the client to take deep breaths.
ANS: A
B. Evaluate the integrity of the IV insertion site.
C. Assess distal lower extremity capillary refill.
D. Check femoral site for hematoma formation.
ANS: B
, lOMoAR cPSD| 19693624 lOMoAR cPSD| 19693624
8. A 7-year old is admitted to the hospital with persistent vomiting, and nasogastric tube attached to low 11. Which needle should the nurse use to administer intravenous fluids (IV) via a client’s implanted port?
intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare
provider?
A. Shift intake of 640 ml IV fluids plus 30 ml PO ice chips.
B. Serum pH of 7.45
C. Serum potassium of 3.0 mg/dl.
D. Gastric output of 100 ml in the last 8 hours.
ANS: C
9. A morbidly obese client is scheduled for gastric bypass surgery. The client completes the required
preoperative nutritional counselling and signs the operative permit. To promote effective discharge planning,
which intervention is most important for the nurse to implement?
A. Discuss small, low fat, low sugar meal preparation techniques.
B. Advise the client to arrange for dietary counselling after discharged.
C. Encourage the client to keep a daily diary for two weeks. ANS: C
D. Suggest that the client’s spouse do the family grocery shopping.
ANS: A 12. An older client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client
is aphasic with left-side paresis and is having difficulty swallowing. Which intervention is most important for
the nurse to include in the client’s plan of care?
10.The nurse is admitting a client from the post anesthesia unit to the postoperative surgical care unit. Which A. Use pictures and gestures to communicate.
prescription should the nurse implement first?
B. Arrange for daily home care assistance.
A. Cefazolin 1-gram IVPB q6 hours.
C. Facilitate a consultation for speech therapy.
B. Complete blood cell count (CBC) in AM.
D. Initiate passive range of motion exercises.
C. Straight catherization if unable to void.
ANS: C
D. Advance from clear liquid as tolerated.
ANS:
13. A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the
nurse implement?
A. Assess the client for the presence of hemorrhoids.
B. Administer a prescribed PRN antiemetic.
C. Check the client’s hemoglobin level.
D. Review the client’s current list of medications
ANS: D
, lOMoAR cPSD| 19693624 lOMoAR cPSD| 19693624
14. A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child 18. The nurse enters the room of a client with Parkinson’s disease who is taking carbidopa levodopa. The client
got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What
clothes. After ensuring the airway is patent, what action should the nurse implement first? action should the nurse take?
A. Call poison control emergency number. A. Tell the UAP to assist the client in moving more quickly.
B. Determine type of chemical exposure. B. Offer PRN analgesic to reduce painful movement.
C. Obtain equipment for gastric lavage. C. Affirm that the client should arise slowly from the chair.
D. Assess child for altered sensorium. D. Demonstrate how to help the client move more efficiently.
ANS: D ANS: C
15. When should the nurse conduct an Allen’s test? 19. Which assessment is more important for the nurse to include in the daily plan of care for a client with a
burned extremity?
A. Prior to attempting a cardiac output calculation.
A. Range of Motion
B. When pulmonary artery pressures are obtained.
B. Distal pulse intensity
C. Just before arterial blood gasses are drawn peripherally.
C. Extremity sensation
D. To assess for presence of deep vein thrombus in the leg.
D. Presence of exudate
ANS: C
ANS: B
16. A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work
an 8 hour shift. Which client is best to assign to this nurse? 20. Client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right
arm is no longer available for use for hemodialysis. The client has lost weight, has increasing peripheral edema,
A. A mother with an infected episiotomy
and has a serum albumin level of 1.5 g/dl (15 g/L). Which intervention is the priority for the nurse to
B. A client who is leaking clear fluid. implement?
C. A client at 28-weeks gestation in pre-term labor. A. Instruct the client to continue to follow the prescribed rigid fluid restriction amount.
D. A mother who just delivered a 9-pound baby. B. Evaluate patency of the AV graft for resumption of hemodialysis.
ANS: A C. Ensure the client receives frequent small meals containing complete proteins.
D. Recommend the use of support stocking to enhance venous return.
17. A 300 ml unit of packed red blood cells is prescribed for a client with heart failure (HF) who has 3+ pitting ANS: C
edema, shortness of breath with any activity, and activity, and crackles in both lung bases. What rate should the
nurse administer the blood?
A. 150 ml/hour.
B. 75 ml/hour.
C. 300 ml/hour.
D. 50 ml/hour.
ANS: A
lOMoAR cPSD| 19693624
4. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated
and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing
HESI RN EXIT EXAM V2 2023 (+900 score!)|A GRADED intervention should the nurse implement?
A. Instruct the mother to change the child’s diaper more often.
1. The school nurse is preparing a presentation for a elementary school teachers to inform teachers to inform B. Encourage the mother to apply lotion with each diaper change.
them about when a child should be referred to the school clinic for further follow-up. The teachers should be
instructed to report which situations to the school nurse? (Select all that apply) C. Ask the mother to decrease the infant’s intake of fruits for 24 hours.
A. Refuses to complete written homework assignments. D. Tell the mother to cleanse with soap and water at each diaper change.
B. Thirst and frequent requests for bathroom breaks. ANS: A
C. Bruises on both knees after the weekend.
D. Sunburn with blisters on the face, arms, and hands. 5. The nurse is having difficulty palpating a client’s posterior tibial pulse while the client is lying in a supine
position?
E. Shaking that changes the child’s hand writing.
A. Extend the client’s arm fully while supporting the elbow and attempt to repalpate.
ANS: B D E
B. Apply less pressure when palpating over the middle of the dorsum of the foot.
C. Use an ultrasound stethoscope place behind and below the medial bone.
2. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to
treat bladder cancer, which instruction is most important for the nurse to include in the client’s discharge D. Help the client to a prone position with the knee slightly flexed and palpate again.
teaching plan? ANS: D
A. Report any signs of cloudy urine output.
B. Frequent empty bladder to avoid distention. 6. The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which
C. Follow instructions for self-care toileting. outcome indicates that the program was effective?
D. Seek counselling for body image. A. Average client scores improved on specific risk factor knowledge tests.
ANS: A B. Only 30% of clients did not attend self-management education sessions.
C. More that 50% of at-risk clients were diagnosed early in the disease process.
3. A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic. Which D. Client who developed disease complications promptly received rehabilitation.
assessment finding should prompt the nurse to administer a PRN dose of naloxone? ANS: D
A. Unresponsive to verbal or tactile stimuli.
B. Respiratory rate of 12 breath/minute. 7. A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin
C. Statements about visual hallucinations. are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client
complains of pain at the right groin insertion site. What action should the nurse implement?
D. Complaints of increasing flank pain.
A. Stimulate the client to take deep breaths.
ANS: A
B. Evaluate the integrity of the IV insertion site.
C. Assess distal lower extremity capillary refill.
D. Check femoral site for hematoma formation.
ANS: B
, lOMoAR cPSD| 19693624 lOMoAR cPSD| 19693624
8. A 7-year old is admitted to the hospital with persistent vomiting, and nasogastric tube attached to low 11. Which needle should the nurse use to administer intravenous fluids (IV) via a client’s implanted port?
intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare
provider?
A. Shift intake of 640 ml IV fluids plus 30 ml PO ice chips.
B. Serum pH of 7.45
C. Serum potassium of 3.0 mg/dl.
D. Gastric output of 100 ml in the last 8 hours.
ANS: C
9. A morbidly obese client is scheduled for gastric bypass surgery. The client completes the required
preoperative nutritional counselling and signs the operative permit. To promote effective discharge planning,
which intervention is most important for the nurse to implement?
A. Discuss small, low fat, low sugar meal preparation techniques.
B. Advise the client to arrange for dietary counselling after discharged.
C. Encourage the client to keep a daily diary for two weeks. ANS: C
D. Suggest that the client’s spouse do the family grocery shopping.
ANS: A 12. An older client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client
is aphasic with left-side paresis and is having difficulty swallowing. Which intervention is most important for
the nurse to include in the client’s plan of care?
10.The nurse is admitting a client from the post anesthesia unit to the postoperative surgical care unit. Which A. Use pictures and gestures to communicate.
prescription should the nurse implement first?
B. Arrange for daily home care assistance.
A. Cefazolin 1-gram IVPB q6 hours.
C. Facilitate a consultation for speech therapy.
B. Complete blood cell count (CBC) in AM.
D. Initiate passive range of motion exercises.
C. Straight catherization if unable to void.
ANS: C
D. Advance from clear liquid as tolerated.
ANS:
13. A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the
nurse implement?
A. Assess the client for the presence of hemorrhoids.
B. Administer a prescribed PRN antiemetic.
C. Check the client’s hemoglobin level.
D. Review the client’s current list of medications
ANS: D
, lOMoAR cPSD| 19693624 lOMoAR cPSD| 19693624
14. A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child 18. The nurse enters the room of a client with Parkinson’s disease who is taking carbidopa levodopa. The client
got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What
clothes. After ensuring the airway is patent, what action should the nurse implement first? action should the nurse take?
A. Call poison control emergency number. A. Tell the UAP to assist the client in moving more quickly.
B. Determine type of chemical exposure. B. Offer PRN analgesic to reduce painful movement.
C. Obtain equipment for gastric lavage. C. Affirm that the client should arise slowly from the chair.
D. Assess child for altered sensorium. D. Demonstrate how to help the client move more efficiently.
ANS: D ANS: C
15. When should the nurse conduct an Allen’s test? 19. Which assessment is more important for the nurse to include in the daily plan of care for a client with a
burned extremity?
A. Prior to attempting a cardiac output calculation.
A. Range of Motion
B. When pulmonary artery pressures are obtained.
B. Distal pulse intensity
C. Just before arterial blood gasses are drawn peripherally.
C. Extremity sensation
D. To assess for presence of deep vein thrombus in the leg.
D. Presence of exudate
ANS: C
ANS: B
16. A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work
an 8 hour shift. Which client is best to assign to this nurse? 20. Client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right
arm is no longer available for use for hemodialysis. The client has lost weight, has increasing peripheral edema,
A. A mother with an infected episiotomy
and has a serum albumin level of 1.5 g/dl (15 g/L). Which intervention is the priority for the nurse to
B. A client who is leaking clear fluid. implement?
C. A client at 28-weeks gestation in pre-term labor. A. Instruct the client to continue to follow the prescribed rigid fluid restriction amount.
D. A mother who just delivered a 9-pound baby. B. Evaluate patency of the AV graft for resumption of hemodialysis.
ANS: A C. Ensure the client receives frequent small meals containing complete proteins.
D. Recommend the use of support stocking to enhance venous return.
17. A 300 ml unit of packed red blood cells is prescribed for a client with heart failure (HF) who has 3+ pitting ANS: C
edema, shortness of breath with any activity, and activity, and crackles in both lung bases. What rate should the
nurse administer the blood?
A. 150 ml/hour.
B. 75 ml/hour.
C. 300 ml/hour.
D. 50 ml/hour.
ANS: A
