HESI EXIT EXAM V1-7 2025
C
Terms in this set (818)
Following discharge teaching, a Review with the client the need to avoid foods that are rich in
male client with duodenal ulcer milk and cream
tells the nurse the he will drink
plenty of dairy products, such as Rationale: Diets rich in milk and cream stimulate gastric acid
milk, to help coat and protect secretion and should be avoided.
his ulcer. What is the best
follow-up action by the nurse?
a. Remind the client that it is also
important to switch to
decaffeinated coffee and tea.
b. Suggest that the client also
plan to eat frequent small meals
to reduce discomfort
c. Review with the client the
need to avoid foods that are rich
in milk and cream.
d. Reinforce this teaching by
asking the client to list a dairy
food that he might select.
,A male client with hypertension, Stroke secondary to hemorrhage
who received new
antihypertensive prescriptions at Rationale: Stroke related to cerebral hemorrhage is major risk for
his last visit returns to the clinic uncontrolled hypertension.
two weeks later to evaluate his
blood pressure (BP). His BP is
158/106 and he admits that he
has not been taking the
prescribed medication because
the drugs make him "feel bad".
In explaining the need for
hypertension control, the nurse
should stress that an elevated
BP places the client at risk for
which pathophysiological
condition?
a. Blindness secondary to
cataracts
b. Acute kidney injury due to
glomerular damage
c. Stroke secondary to
hemorrhage
d. Heart block due to
myocardial damage
The nurse observes an Instruct the UAP to obtain soft blankets to secure to the side rails
unlicensed assistive personnel instead of pillows
(UAP) positioning a newly
admitted client who has a Rationale: The nurse should instruct the UAP to pad the side rails
seizure disorder. The client is with soft blankest because the use of pillows could result in
supine and the UAP is placing suffocation and would need to be removed at the onset of the
soft pillows along the side rails. seizure. The nurse can delegate paddling the side rails to the
What action should the nurse UAP
implement?
a. Ensure that the UAP has
placed the pillows effectively to
protect the client.
b. Instruct the UAP to obtain soft
blankets to secure to the side
rails instead of pillows.
c. Assume responsibility for
placing the pillows while the
UAP completes another task.
d. Ask the UAP to use some of
the pillows to prop the client in
a side lying position.
,An adolescent with major Describes life without purpose
depressive disorder has been
taking duloxetine (Cymbalta) for Rationale: Cymbalta is a selective serotonin and norepinephrine
the past 12 days. Which reuptake inhibitor that is known to increase the risk of suicidal
assessment finding requires thinking in adolescents and young adults with major depressive
immediate follow-up disorder. B, C and D are side effects
a. Describes life without
purpose
b. Complains of nausea and loss
of appetite
c. States is often fatigued and
drowsy
d. Exhibits an increase in
sweating.
A 60-year-old female client with Further evaluation involving surgery may be needed
a positive family history of
ovarian cancer has developed Rationale: An abdominal mass in a client with a family history for
an abdominal mass and is being ovarian cancer should be evaluated carefully
evaluated for possible ovarian
cancer. Her Papanicolau (Pap)
smear results are negative. What
information should the nurse
include in the client's teaching
plan
a. Further evaluation involving
surgery may be needed
b. A pelvic exam is also needed
before cancer is ruled out
c. Pap smear evaluation should
be continued every six month
d. One additional negative pap
smear in six months is needed.
A client who recently underwent Teach tracheal suctioning techniques
a tracheostomy is being
prepared for discharge to home. Rationale: Suctioning helps to clear secretions and maintain an
Which instructions is most open airway, which is critical.
important for the nurse to
include in the discharge plan?
a. Explain how to use
communication tools.
b. Teach tracheal suctioning
techniques
c. Encourage self-care and
independence.
d. Demonstrate how to clean
tracheostomy site.
, In assessing an adult client with Document the assessment data
a partial rebreather mask, the
nurse notes that the oxygen Rational: reservoir bag should not deflate completely during
reservoir bag does not deflate inspiration and the client's respiratory rate is within normal limits.
completely during inspiration
and the client's respiratory rate
is 14 breaths / minute. What
action should the nurse
implement
a. Encourage the client to take
deep breaths
b. Remove the mask to deflate
the bag
c. Increase the liter flow of
oxygen
d. Document the assessment
data
During shift report, the central Respiratory apnea of 30 seconds
electrocardiogram (EKG)
monitoring system alarms. Rationale: The priority is the client whose alarm indicating
Which client alarm should the respiratory apnea that should be assessed first.
nurse investigate first?
a. Respiratory apnea of 30
seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular
beats every minute
d. Disconnected monitor signal
for the last 6 minutes.
During a home visit, the nurse Check the client for lacerations or fractures
observed an elderly client with
diabetes slip and fall. What Rationale: After the client falls, the nurse should immediately
action should the nurse take assess for the possibility of injuries and provide first aid as
first? needed
a. Give the client 4 ounces of
orange juice
b. Call 911 to summon
emergency assistance
c. Check the client for
lacerations or fractures
d. Asses clients blood sugar
level
C
Terms in this set (818)
Following discharge teaching, a Review with the client the need to avoid foods that are rich in
male client with duodenal ulcer milk and cream
tells the nurse the he will drink
plenty of dairy products, such as Rationale: Diets rich in milk and cream stimulate gastric acid
milk, to help coat and protect secretion and should be avoided.
his ulcer. What is the best
follow-up action by the nurse?
a. Remind the client that it is also
important to switch to
decaffeinated coffee and tea.
b. Suggest that the client also
plan to eat frequent small meals
to reduce discomfort
c. Review with the client the
need to avoid foods that are rich
in milk and cream.
d. Reinforce this teaching by
asking the client to list a dairy
food that he might select.
,A male client with hypertension, Stroke secondary to hemorrhage
who received new
antihypertensive prescriptions at Rationale: Stroke related to cerebral hemorrhage is major risk for
his last visit returns to the clinic uncontrolled hypertension.
two weeks later to evaluate his
blood pressure (BP). His BP is
158/106 and he admits that he
has not been taking the
prescribed medication because
the drugs make him "feel bad".
In explaining the need for
hypertension control, the nurse
should stress that an elevated
BP places the client at risk for
which pathophysiological
condition?
a. Blindness secondary to
cataracts
b. Acute kidney injury due to
glomerular damage
c. Stroke secondary to
hemorrhage
d. Heart block due to
myocardial damage
The nurse observes an Instruct the UAP to obtain soft blankets to secure to the side rails
unlicensed assistive personnel instead of pillows
(UAP) positioning a newly
admitted client who has a Rationale: The nurse should instruct the UAP to pad the side rails
seizure disorder. The client is with soft blankest because the use of pillows could result in
supine and the UAP is placing suffocation and would need to be removed at the onset of the
soft pillows along the side rails. seizure. The nurse can delegate paddling the side rails to the
What action should the nurse UAP
implement?
a. Ensure that the UAP has
placed the pillows effectively to
protect the client.
b. Instruct the UAP to obtain soft
blankets to secure to the side
rails instead of pillows.
c. Assume responsibility for
placing the pillows while the
UAP completes another task.
d. Ask the UAP to use some of
the pillows to prop the client in
a side lying position.
,An adolescent with major Describes life without purpose
depressive disorder has been
taking duloxetine (Cymbalta) for Rationale: Cymbalta is a selective serotonin and norepinephrine
the past 12 days. Which reuptake inhibitor that is known to increase the risk of suicidal
assessment finding requires thinking in adolescents and young adults with major depressive
immediate follow-up disorder. B, C and D are side effects
a. Describes life without
purpose
b. Complains of nausea and loss
of appetite
c. States is often fatigued and
drowsy
d. Exhibits an increase in
sweating.
A 60-year-old female client with Further evaluation involving surgery may be needed
a positive family history of
ovarian cancer has developed Rationale: An abdominal mass in a client with a family history for
an abdominal mass and is being ovarian cancer should be evaluated carefully
evaluated for possible ovarian
cancer. Her Papanicolau (Pap)
smear results are negative. What
information should the nurse
include in the client's teaching
plan
a. Further evaluation involving
surgery may be needed
b. A pelvic exam is also needed
before cancer is ruled out
c. Pap smear evaluation should
be continued every six month
d. One additional negative pap
smear in six months is needed.
A client who recently underwent Teach tracheal suctioning techniques
a tracheostomy is being
prepared for discharge to home. Rationale: Suctioning helps to clear secretions and maintain an
Which instructions is most open airway, which is critical.
important for the nurse to
include in the discharge plan?
a. Explain how to use
communication tools.
b. Teach tracheal suctioning
techniques
c. Encourage self-care and
independence.
d. Demonstrate how to clean
tracheostomy site.
, In assessing an adult client with Document the assessment data
a partial rebreather mask, the
nurse notes that the oxygen Rational: reservoir bag should not deflate completely during
reservoir bag does not deflate inspiration and the client's respiratory rate is within normal limits.
completely during inspiration
and the client's respiratory rate
is 14 breaths / minute. What
action should the nurse
implement
a. Encourage the client to take
deep breaths
b. Remove the mask to deflate
the bag
c. Increase the liter flow of
oxygen
d. Document the assessment
data
During shift report, the central Respiratory apnea of 30 seconds
electrocardiogram (EKG)
monitoring system alarms. Rationale: The priority is the client whose alarm indicating
Which client alarm should the respiratory apnea that should be assessed first.
nurse investigate first?
a. Respiratory apnea of 30
seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular
beats every minute
d. Disconnected monitor signal
for the last 6 minutes.
During a home visit, the nurse Check the client for lacerations or fractures
observed an elderly client with
diabetes slip and fall. What Rationale: After the client falls, the nurse should immediately
action should the nurse take assess for the possibility of injuries and provide first aid as
first? needed
a. Give the client 4 ounces of
orange juice
b. Call 911 to summon
emergency assistance
c. Check the client for
lacerations or fractures
d. Asses clients blood sugar
level
