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Exam (elaborations)

HESI RN EXIT EXAM QUESTIONS AND VERIFIED ANSWERS

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HESI RN EXIT EXAM QUESTIONS AND VERIFIED ANSWERS

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HESI RN EXIT EXAM QUESTIONS AND
VERIFIED ANSWERS
A client with pneumococcal pneumonia had been started on antibiotics 16 hours
ago.During the nurse's initial evening rounds the nurse notices a foul smell in the
room. The client makes all of these statements during their conversation. Which
statement would alert the nurse to a complication?
A) "I have a sharp pain in my chest when I take a breath.
"B) "I have been coughing up foul-tasting, brown, thick sputum.
" C) "I have been sweating all day.
"D) "I feel hot off and on." - ANSWER-"B) "I have been coughing up foul-tasting,
brown, thick sputum.

The nurse is performing an assessment on a client in congestive heart failure.
Auscultation of the heart is most likely to reveal
A) S3 ventricular gallop
B) Apical click
C) Systolic murmur
D) Split S2 - ANSWER-A) S3 ventricular gallop

Which of these observations made by the nurse during an excretory urogram
indicate a complicaton?
A) The client complains of a salty taste in the mouth when the dye is injected
B) The client's entire body turns a bright red color
C) The client states "I have a feeling of getting warm."
D) The client gags and complains " I am getting sick." - ANSWER-B) The client's
entire body turns a bright red color

A client is diagnosed with a spontaneous pneumothorax necessitating the insertion
of a chest tube. What is the best explanation for the nurse to provide this client?
A) "The tube will drain fluid from your chest.
"B) "The tube will remove excess air from your chest."
C) "The tube controls the amount of air that enters your chest.
" D) "The tube will seal the hole in your lung." - ANSWER-"B) "The tube will remove
excess air from your chest."

The nurse is reviewing laboratory results on a client with acute renal failure. Which
one of the following should be reported immediately?
A) Blood urea nitrogen 50 mg/dl
B) Hemoglobin of 10.3 mg/dl
C) Venous blood pH 7.30
D) Serum potassium 6 mEq/L - ANSWER-D) Serum potassium 6 mEq/L

The nurse is caring for a client undergoing the placement of a central venous
catheter line. Which of the following would require the nurse's immediate attention?
A) Pallor
B) Increased temperature
C) Dyspnea

,D) Involuntary muscle spasms - ANSWER-C) Dyspnea

The nurse is performing a physical assessment on a client who just had an
endotracheal tube inserted. Which finding would call for immediate action by the
nurse?
A) Breath sounds can be heard bilaterally
B) Mist is visible in the T-Piece
C) Pulse oximetry of 88
D) Client is unable to speak - ANSWER-C) Pulse oximetry of 88

A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates
that the client may need suctioning?A) Drowsiness
B) Complaint of nausea
C) Pulse rate of 92
D) Restlessness - ANSWER-D) Restlessness

During the evaluation phase for a client, the nurse should focus on
A) All finding of physical and psychosocial stressors of the client and in the family
B) The client's status, progress toward goal achievement, and ongoing re-evaluation
C) Setting short and long-term goals to insure continuity of care from hospital to
home
D) Select interventions that are measurable and achievable within selected
timeframes - ANSWER-B) The client's status, progress toward goal achievement,
and ongoing re-evaluation

The school nurse suspects that a third grade child might have Attention Deficit
Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse
should
A) Observe the child's behavior on at least 2 occasions
B) Consult with the teacher about how to control impulsivity
C) Compile a history of behavior patterns and developmental accomplishments
D) Compare the child's behavior with classic signs and symptoms - ANSWER-C)
Compile a history of behavior patterns and developmental accomplishments

Which of the actions suggested to the RN by the PN during a planning conference
for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be
acceptable to add to the plan of care?
A) Measure head circumference
B) Place in airborne isolation
C) Provide passive range of motion
D) Provide an over-the-crib protective top - ANSWER-A) Measure head
circumference


Which these findings would the nurse more closely associate with anemia in a 10
month-old infant?
A) Hemoglobin level of 12 g/dI
B) Pale mucosa of the eyelids and lips
C) Hypoactivity

, D) A heart rate between 140 to 160 - ANSWER-B) Pale mucosa of the eyelids and
lips

The nurse is caring for a client in hypertensive crisis in an intensive care unit. The
priority assessment in the first hour of care is
A) Heart rate
B) Pedal pulses
C) Lung sounds
D) Pupil responses - ANSWER-D) Pupil responses

Which of these clients who are all in the terminal stage of cancer is least appropriate
to suggest the use of patient controlled analgesia (PCA) with a pump?
A) A young adult with a history of Down's syndrome
B) A teenager who reads at a 4th grade level
C) An elderly client with numerous arthritic nodules on the hands
D) A preschooler with intermittent episodes of alertness - ANSWER-D) A
preschooler with intermittent episodes of alertness

The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive
(NOFTT). Upon entering the room, the nurse would expect the baby to be
A) Irritable and "colicky" with no attempts to pull to standing
B) Alert, laughing and playing with a rattle, sitting with support
C) Skin color dusky with poor skin turgor over abdomen
D) Pale, thin arms and legs, uninterested in surroundings - ANSWER-D) Pale, thin
arms and legs, uninterested in surroundings

As the nurse is speaking with a group of teens which of these side effects of
chemotherapy for cancer would the nurse expect this group to be more interested in
during the discussion?
A) Mouth sores
B) Fatigue
C) Diarrhea
D) Hair loss - ANSWER-D) Hair loss

While caring for a client who was admitted with myocardial infarction (MI) 2 days
ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5
degreesCelsius). The appropriate nursing intervention is to
A) Call the health care provider immediately
B) Administer acetaminophen as ordered as this is normal at this time
C) Send blood, urine and sputum for culture
D) Increase the client's fluid intake - ANSWER-B) Administer acetaminophen as
ordered as this is normal at this time

A client is admitted for first and second degree burns on the face, neck, anterior
chest and hands. The nurse's priority should be
A) Cover the areas with dry sterile dressings
B) Assess for dyspnea or stridor
C) Initiate intravenous therapy
D) Administer pain medication - ANSWER-B) Assess for dyspnea or stridor

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