HESI RN EXIT EXAM VERSION
1 [V1] 160 QUESTIONS AND ANSWERS
WITH PICTURES AND DRAWINGS
1. The nurse is reviewing medical prescriptions for newly admitted clients. It wouldbe a
priority for the nurse to follow up with the physician if a client with
(a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene) prescribed
(b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure
precautions(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed
Tylenol (acetaminophen)
(d) sensitivity to Penicillin is prescribed Zithromax (azithromycin)
2. The nurse should intervene if the nurse notes a staff member
(a) obtaining a clients consent prior to their operative procedure after
receiving Ativan (lorazepam)
(b) placing a client on the affected side following surgical
repair of a retinal detachment
(c) handling a wet cast with the palms of the hands
(d) using a broad base of support while transferring a client
3. The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client who is
(a) 12 years old with Autism who is starting a new school and
recently had aURI (upper respiratory tract infection)
(b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and
had a recent Hemoglobin A1c of 13%
(c) 52 years old, with Myasthenia Gravis, recently
4
, prescribed Mestinon (pyridostigmine) and employed
as a mail carrier
(d) 70 years old, has schizophrenia, lives alone and reports hearing non threateningvoices.
4. The nurse from the postpartum unit has been temporarily assigned to the
medical surgical unit. It would be most appropriate to assign this nurse to
the client who*
(a) has returned from right total hip replacement surgery four hours ago
(b) is being observed for increased intracranial pressure
(c) had surgery two hours ago to remove the appendix
(d) is two weeks post partum being maintained on a mechanical
ventilator for respiratory failure
5. The nurse in a well baby clinic has assessed several children today. It
would be a priority for the nurse to suggest follow up for the child who is (a)
2 months old with apositive babinski refl ex
(b) 5 months old and does not hold their own bottle
(c) 10 months old who cries around strangers
(d) 18 months old who needs support while ambulating
6. The nurse is caring for a mechanically ventilated client who was declared brain
dead. An Advance Directive is not documented on the medical record. It would be
most appropriate to obtain consent for organ donation from the
(a) client‘s primary care provider
(b) client‘s nurse manager
(c) closest living family member
(d) hospital‘s ethics committee
7. The nurse has received report on four clients. The nurse should fi rst
assess theclient who has*
(a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of90%
(b) Parkinson‘s Disease and is demanding to leave the hospital against medical
, advice(AMA)
(c) been admitted with suspected Guillian-Barre´ Syndrome
and has begun plasmapheresis therapy
(d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+)
8. It would be appropriate to assign which of these tasks to the CNA?
(a) Feeding a client who is experiencing dysphagia
(b) One-on-one client observation for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change
9. The nurse should intervene if a staff member is observed
(a) discussing a client‘s diagnosis with visiting family members
(b) collaborating with another nurse to review a prescription for blood transfusion
(c) interrupting other staff members discussing a client in the cafeteria
10. reviewing a clients lab values with the nutritionist The nurse is preparing a
staff presentation on legal and ethical issues in nursing.The nurse would be
correct to include which of the following examples?
(a) Putting a client in a geriatric chair with the lap tray in front of the client in the
dayroom to watch television is false imprisonment
(b) Telling a client that you will put in a feeding tube if the client does
not eat is an example of battery
(c) Telling a client with bipolar disorder who is suicidal that they have a right to
refuseto take their medications is an example of malpractice
(d) Placing hands on a client who says ―do not touch me‖ is an example of assault
11. The nurse from the pediatric unit has been temporarily assigned to the
Emergency Department. It would be most appropriate to assign that nurse
to the client who*
(a) reports epigastric pain that ―feels like indigestion‖
(b) has back pain and a pulsating abdominal mass
4
, (c) is HIV+ reporting vomiting and diarrhea
(d) presents with lower abdominal pain and is six weeks pregnant
12. Four clients recently returned to the unit following invasive diagnostic testing.
Thenurse should immediately intervene if one of the clients
(a) reports blood tinged sputum following a bronchoscopy
(b) has decreased abdominal girth following paracentesis
(c) reports a headache following a lumbar puncture
(d) is observed flexing and extending the legs two hours after cardiac catheterization
13. The nurse is made aware of the following situations. The nurse should fi rst
checkthe client who
(a) had a transurethral prostatectomy (TURP) and is reporting urinary
dribbling twohours after the indwelling catheter is removed
(b) has cervical traction and is moving the legs by fl exing and extending the feet
(c) has Alzheimer‘s disease (stage 1) and was returned to the room after
being found wandering in the hallway
(d) has a history of partial seizures and is sitting in the bed picking at the
clothing and smacking the lips
14. The nurse in a community health clinic is talking with the parent of a child
withCeliac Disease. Which of the following statements would require follow-
up by the
1 [V1] 160 QUESTIONS AND ANSWERS
WITH PICTURES AND DRAWINGS
1. The nurse is reviewing medical prescriptions for newly admitted clients. It wouldbe a
priority for the nurse to follow up with the physician if a client with
(a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene) prescribed
(b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure
precautions(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed
Tylenol (acetaminophen)
(d) sensitivity to Penicillin is prescribed Zithromax (azithromycin)
2. The nurse should intervene if the nurse notes a staff member
(a) obtaining a clients consent prior to their operative procedure after
receiving Ativan (lorazepam)
(b) placing a client on the affected side following surgical
repair of a retinal detachment
(c) handling a wet cast with the palms of the hands
(d) using a broad base of support while transferring a client
3. The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client who is
(a) 12 years old with Autism who is starting a new school and
recently had aURI (upper respiratory tract infection)
(b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and
had a recent Hemoglobin A1c of 13%
(c) 52 years old, with Myasthenia Gravis, recently
4
, prescribed Mestinon (pyridostigmine) and employed
as a mail carrier
(d) 70 years old, has schizophrenia, lives alone and reports hearing non threateningvoices.
4. The nurse from the postpartum unit has been temporarily assigned to the
medical surgical unit. It would be most appropriate to assign this nurse to
the client who*
(a) has returned from right total hip replacement surgery four hours ago
(b) is being observed for increased intracranial pressure
(c) had surgery two hours ago to remove the appendix
(d) is two weeks post partum being maintained on a mechanical
ventilator for respiratory failure
5. The nurse in a well baby clinic has assessed several children today. It
would be a priority for the nurse to suggest follow up for the child who is (a)
2 months old with apositive babinski refl ex
(b) 5 months old and does not hold their own bottle
(c) 10 months old who cries around strangers
(d) 18 months old who needs support while ambulating
6. The nurse is caring for a mechanically ventilated client who was declared brain
dead. An Advance Directive is not documented on the medical record. It would be
most appropriate to obtain consent for organ donation from the
(a) client‘s primary care provider
(b) client‘s nurse manager
(c) closest living family member
(d) hospital‘s ethics committee
7. The nurse has received report on four clients. The nurse should fi rst
assess theclient who has*
(a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of90%
(b) Parkinson‘s Disease and is demanding to leave the hospital against medical
, advice(AMA)
(c) been admitted with suspected Guillian-Barre´ Syndrome
and has begun plasmapheresis therapy
(d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+)
8. It would be appropriate to assign which of these tasks to the CNA?
(a) Feeding a client who is experiencing dysphagia
(b) One-on-one client observation for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change
9. The nurse should intervene if a staff member is observed
(a) discussing a client‘s diagnosis with visiting family members
(b) collaborating with another nurse to review a prescription for blood transfusion
(c) interrupting other staff members discussing a client in the cafeteria
10. reviewing a clients lab values with the nutritionist The nurse is preparing a
staff presentation on legal and ethical issues in nursing.The nurse would be
correct to include which of the following examples?
(a) Putting a client in a geriatric chair with the lap tray in front of the client in the
dayroom to watch television is false imprisonment
(b) Telling a client that you will put in a feeding tube if the client does
not eat is an example of battery
(c) Telling a client with bipolar disorder who is suicidal that they have a right to
refuseto take their medications is an example of malpractice
(d) Placing hands on a client who says ―do not touch me‖ is an example of assault
11. The nurse from the pediatric unit has been temporarily assigned to the
Emergency Department. It would be most appropriate to assign that nurse
to the client who*
(a) reports epigastric pain that ―feels like indigestion‖
(b) has back pain and a pulsating abdominal mass
4
, (c) is HIV+ reporting vomiting and diarrhea
(d) presents with lower abdominal pain and is six weeks pregnant
12. Four clients recently returned to the unit following invasive diagnostic testing.
Thenurse should immediately intervene if one of the clients
(a) reports blood tinged sputum following a bronchoscopy
(b) has decreased abdominal girth following paracentesis
(c) reports a headache following a lumbar puncture
(d) is observed flexing and extending the legs two hours after cardiac catheterization
13. The nurse is made aware of the following situations. The nurse should fi rst
checkthe client who
(a) had a transurethral prostatectomy (TURP) and is reporting urinary
dribbling twohours after the indwelling catheter is removed
(b) has cervical traction and is moving the legs by fl exing and extending the feet
(c) has Alzheimer‘s disease (stage 1) and was returned to the room after
being found wandering in the hallway
(d) has a history of partial seizures and is sitting in the bed picking at the
clothing and smacking the lips
14. The nurse in a community health clinic is talking with the parent of a child
withCeliac Disease. Which of the following statements would require follow-
up by the
