HESI Exit v2
1. The nurse knows which statement by the mother indicates that the moth- er
understands safety precautions with her four month-old infant and her 4year-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 buttocksstuck 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 bottle in the
kitchen
while I make supper.": Ans: D: "I have the four year-old hold and help feed the four
month-old a bottle in the kitchen
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;: Ans: B: Give informa- tion about advance
directives
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: Ans: B: Administer epinephrine 1:1000 as
ordered .
4. Which of these children at the site of a disaster at a child day care center would
thea 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: Ans: B: A toddler
with severe deep abrasions over 98% of the body .
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: Ans: C: notify the
admissions office and wait to apply the bracelet
6. The nurse is having difficulty reading the health care provider's writtenorder 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
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification: Ans: D: Call the provider for clarification
7. An adult client is found to be unresponsive on morning rounds. After Checking for
responsiveness and calling for help, the next action that should be taken by the nurse
is to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway: Ans: D: open the client''s airway
8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse
discovers that 800 ml has been infused after 4 hours. What is the priority nursing
, action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs: Ans: D: Auscultate the lungs
9. Following change-of-shift report on an orthopedic unit, which client should the
nurse
see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motorcycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery.: The
1. The nurse knows which statement by the mother indicates that the moth- er
understands safety precautions with her four month-old infant and her 4year-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 buttocksstuck 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 bottle in the
kitchen
while I make supper.": Ans: D: "I have the four year-old hold and help feed the four
month-old a bottle in the kitchen
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;: Ans: B: Give informa- tion about advance
directives
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: Ans: B: Administer epinephrine 1:1000 as
ordered .
4. Which of these children at the site of a disaster at a child day care center would
thea 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: Ans: B: A toddler
with severe deep abrasions over 98% of the body .
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: Ans: C: notify the
admissions office and wait to apply the bracelet
6. The nurse is having difficulty reading the health care provider's writtenorder 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
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification: Ans: D: Call the provider for clarification
7. An adult client is found to be unresponsive on morning rounds. After Checking for
responsiveness and calling for help, the next action that should be taken by the nurse
is to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway: Ans: D: open the client''s airway
8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse
discovers that 800 ml has been infused after 4 hours. What is the priority nursing
, action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs: Ans: D: Auscultate the lungs
9. Following change-of-shift report on an orthopedic unit, which client should the
nurse
see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motorcycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery.: The
