HESI Exit (366 V2) with 160 correct
solutions.
HESI Exit (366 V2) with 160 correct
solutions.
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? - ANSWER "I have the 4 year-old
hold and help feed the four month-old a bottle in the kitchen while I make supper."
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? - ANSWER Give information about advance
directives
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 -
ANSWER Administer epinephrine 1:1000 as ordered
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? - ANSWER A toddler with severe deep abrasions over 98% of the body
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 - ANSWER Notify the admissions
office and wait to apply the bracelet
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? - ANSWER Call the provider for clarification
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: - ANSWER open the client's
airway
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? - ANSWER Auscultate the lungs
,HESI Exit (366 V2) with 160 correct
solutions.
Following change-of-shift report on an orthopedic unit, which client should the nurse see first? -
ANSWER 72 year-old recovering from surgery after a hip replacement 2 hours ago
A nurse observes a family member administer a rectal suppository by having the client lie on the left
side for the administration. The family member pushed the suppository until the finger went up to the
second knuckle. After 10 minutes the client was told by the family member to turn to the right side and
the client did this. What is the appropriate comment for the nurse to make? - ANSWER That was done
correctly. Did you have any problems with the insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of
precautions is the appropriate type to use when performing postmortem care? - ANSWER contact
precautions
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is
appropriate teaching? - ANSWER clean the meatus, begin voiding, then catch urine stream
The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of these
foods would the nurse reinforce for the client to eat at least daily? - ANSWER watermelon
A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? -
ANSWER Immediately wash the hands with vigor
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection,
the nurse notes that the student begins to give the medication without first aspirating. What should the
nurse do? - ANSWER Walk up and whisper in the student's ear "Stop. Aspirate. Then inject."
A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is
independent. What should the nurse document to most accurately describe the client's condition? -
ANSWER Glascow Coma Scale 8, respirations regular
, HESI Exit (366 V2) with 160 correct
solutions.
A client enters the emergency department unconscious via ambulance from the client's work place.
What document should be given priority to guide the direction of care for this client? - ANSWER A
notarized original of advance directives brought in by the partner
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP)
and 1 PN nursing student. Which assignment should be questioned by the nurse manager? - ANSWER An
admission at the change of shifts with atrial fibrillation and heart failure - PN
A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all
the time and has a lot of gas. The nurse expects to find which of the following on the initial history and
physical assessment? - ANSWER Restlessness and increased mucus production
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require
follow-up and are consistent with the diagnosis? - ANSWER "Clothes are becoming tighter across her
abdomen."
A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally
married and signs the consent form for treatment. What would be the appropriate action by the nurse?
- ANSWER Proceed with the triage process in the same manner as any adult client
A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is
appropriate to assign to an unlicensed assistive personnel (UAP)? - ANSWER Report hourly outputs of
less than 30 ml/hr
The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by
the parent would cause the nurse to suspect an association with this disease? - ANSWER Strep throat
went through all the children at the day care last month.
A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to
interact with the client. The next action by the nurse should be to - ANSWER Discuss the feeling of
reluctance with an objective peer or supervisor
solutions.
HESI Exit (366 V2) with 160 correct
solutions.
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? - ANSWER "I have the 4 year-old
hold and help feed the four month-old a bottle in the kitchen while I make supper."
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? - ANSWER Give information about advance
directives
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 -
ANSWER Administer epinephrine 1:1000 as ordered
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? - ANSWER A toddler with severe deep abrasions over 98% of the body
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 - ANSWER Notify the admissions
office and wait to apply the bracelet
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? - ANSWER Call the provider for clarification
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: - ANSWER open the client's
airway
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? - ANSWER Auscultate the lungs
,HESI Exit (366 V2) with 160 correct
solutions.
Following change-of-shift report on an orthopedic unit, which client should the nurse see first? -
ANSWER 72 year-old recovering from surgery after a hip replacement 2 hours ago
A nurse observes a family member administer a rectal suppository by having the client lie on the left
side for the administration. The family member pushed the suppository until the finger went up to the
second knuckle. After 10 minutes the client was told by the family member to turn to the right side and
the client did this. What is the appropriate comment for the nurse to make? - ANSWER That was done
correctly. Did you have any problems with the insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of
precautions is the appropriate type to use when performing postmortem care? - ANSWER contact
precautions
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is
appropriate teaching? - ANSWER clean the meatus, begin voiding, then catch urine stream
The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of these
foods would the nurse reinforce for the client to eat at least daily? - ANSWER watermelon
A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? -
ANSWER Immediately wash the hands with vigor
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection,
the nurse notes that the student begins to give the medication without first aspirating. What should the
nurse do? - ANSWER Walk up and whisper in the student's ear "Stop. Aspirate. Then inject."
A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is
independent. What should the nurse document to most accurately describe the client's condition? -
ANSWER Glascow Coma Scale 8, respirations regular
, HESI Exit (366 V2) with 160 correct
solutions.
A client enters the emergency department unconscious via ambulance from the client's work place.
What document should be given priority to guide the direction of care for this client? - ANSWER A
notarized original of advance directives brought in by the partner
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP)
and 1 PN nursing student. Which assignment should be questioned by the nurse manager? - ANSWER An
admission at the change of shifts with atrial fibrillation and heart failure - PN
A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all
the time and has a lot of gas. The nurse expects to find which of the following on the initial history and
physical assessment? - ANSWER Restlessness and increased mucus production
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require
follow-up and are consistent with the diagnosis? - ANSWER "Clothes are becoming tighter across her
abdomen."
A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally
married and signs the consent form for treatment. What would be the appropriate action by the nurse?
- ANSWER Proceed with the triage process in the same manner as any adult client
A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is
appropriate to assign to an unlicensed assistive personnel (UAP)? - ANSWER Report hourly outputs of
less than 30 ml/hr
The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by
the parent would cause the nurse to suspect an association with this disease? - ANSWER Strep throat
went through all the children at the day care last month.
A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to
interact with the client. The next action by the nurse should be to - ANSWER Discuss the feeling of
reluctance with an objective peer or supervisor
