HESI EXIT EXAM FINAL CAPSTONE 160 QUESTIONS 2025 RATED A

HESI EXIT EXAM FINAL CAPSTONE 160 QUESTIONS 2025 RATED A 1/ A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement? A. Instruct the mother to give the child sugar water only. B. Offer the infant oral rehydration solution every 2 hours. C. Provide Pedialyte feedings via the nasogastric tube. D. Maintain intravenous fluid therapy per prescription. Patient dehydration, electrolyte imbalance, metabolic alkalosis, aspiration, pneumonia NPO IV fluids 2/ A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results show that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important? A. Observe rhythm on telemetry monitor. (QL) B. Check for visual difficulties. C. Assess for hip and hand joint pain. D. Note most recent hemoglobin level. 3/ The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? A. An 8-year-old who lives in a housing project. B. A 2-year-old who plays on aging outdoor playground equipment. (QL) C. An adolescent who works part time in a paint factory. D. A 10-year-old who has Type 1 diabetes mellitus. 4/ The client provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye- opener) questionnaire. Which interpretation should the nurse provide the client? A. The CAGE questionnaire is a tool used to identify general substance abuse. B. At least two positive responses are strongly suggestive of alcohol dependence. C. One positive response indicates the client should seek help with alcohol addiction. D. All responses to the CAGE questionnaire must be positive to suggest alcohol dependence. 5/ In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care? A. Evaluate closest proximal pulse. (QL) B. Note amount and color of wound drainage. C. Observe for swelling around the stump. D. Assess skin elasticity of the stump. 6/ An adolescent with intellectual disability is admitted to the adolescent unit for repeatedly refusing to complete oral hygiene. The healthcare provider prescribes for the client to brush the teeth three times a day. In the psychiatric team conference, a behavior modification program is recommended to engage the client’s participation. When implementing this technique, which reinforcement is best for the nurse to provide? A. Unit tasks for each omission of teeth brushing. B. Candy for each successful hygiene task, like brushing his teeth. C. Privilege restriction or fines for refusing to complete a hygienic task. D. Preferred activities or tokens for each compliance. (QL) 7/ A male client with HIV, who is receiving saquinavir PO in combination with other antiretroviral therapy, tells the home health nurse that he is always hungry and thirsty but seems to be losing weight. What action should the nurse implement? A. Use a glucometer to determine the client’s capillary glucose level. (QL) B. Teach the client strategies to ensure that he measures his weight accurately. C. Explain to the client that he may require an increased dose of his medication. D. Reassure the client that he will gain weight as his viral load decreases. 8/ A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the client’s therapeutic response to this medication, which assessment should the nurse obtain? A. Percussion of abdomen. B. Blood glucose level. C. Serum electrolytes. D. Level of consciousness. (QL) Cirrhosis = hepatic encephalopathy = cloudy brain from ammonia (protein waste) => cannot detox ammonia => build up in blood = mental status changes & twitching extremities 9/ A client with a history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain. Vital signs are: temperature 102F (38.9C), heart rate 138beats/minute, blood pressure 80/60 mmHg. Which intervention should the nurse implement first? A. Obtain an analgesic prescription. B. Infuse an intravenous fluid bolus. (QL) C. Administer PRN oral antipyretic. D. Cover client with cooling blanket. 10/ While changing a client’s chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take? A. Apply a pressure dressing around the chest tube insertion site. B. Administer an oral antihistamine per PRN protocol. x C. Assess the client for allergies to topical cleaning agents. D. Measure the area of swelling and crackling. (QL) 11/ An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? A. Rebound abdominal tenderness. B. Diminished bilateral breath sounds. C. Rib pain with deep inspiration. D. Nausea with projectile vomiting. (QL) Projective vomiting is indicative of increasing intracranial pressure, which can lead to ischemic brain damage or death, so this finding warrants immediate intervention. Rebound abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to pain. Rib pain with inspiration may indicate rib fracture. 12/ A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his “right foot is aching.” The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement? A. Encourage discussion of feelings about the loss of his limb. B. Administer a prescription for gabapentin, a neuroleptic agent. C. Teach the client how to wrap the stump with an elastic bandage. D. Offer to assist the client to a quieter location so he can relax. 13/ An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitation, and vomiting. Which information is most important for the nurse to obtain during the initial interview? A. Recent compliance with prescribed medications. B. Sleep patterns during the previous few weeks. C. History of smoking over the past 6 months. D. Activity level prior to onset of symptoms. 14/ While assisting a client who recently has a hip replacement into the bed pan, the nurse notices that there a small amount of bloody drainage on the surgical dressing, the client’s skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take? A. Obtain a urine sample from the bed pan. B. Insert an indwelling urinary catheter. C. Measure the client’s oral temperature. (QL) D. Remove dressing and assess surgical site. 15/ An older client tells the nurse that itching and excessive tearing caused by severe eye dryness has become increasingly bothersome. The client does not suffer from external eye disease, rhinitis, or hay fever, but also takes several medications. Which medications are likely to have produced this client’s problem? A. Antiinfectives and antidepressants. x B. Anticoagulants and antihistamines. x C. Antiretrovirals and antivirals. x D. Antihypertensives and anticholinergics. (QL) 16/ An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family members are available. What action should the nurse take first? A. Ask the man’s friend to sign the informed consent since the client is unresponsive. B. Notify the unit manager that an emergency court order is needed to allow surgery. C. Continue to provide life support until a thorough search for a guardian is completed. D. Carry on with surgical preparation of the client without a signed informed consent. (QL) 17/ A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client’s admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which actions should the nurse take? (Select all that apply.) (QL) A. Place the client on contact transmission precautions. B. Continue to monitor the client for signs of an infection. C. Obtain a sputum specimen for culture and sensitivity. D. Collect multiple site screening cultures for MRSA. E. Call healthcare provider for a prescription for linezolid. Place – Continue – Collect Except = Obtain sputum & Call HCP 18/ The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement? A. Question the client about the frequency of falls in recent months. B. Request to have the client lie as still as possible for the assessment. C. Ask the client how often episodes of sun downing are experienced. D. Assist the client with values clarification about end-of life care options. 19/ The healthcare provider prescribes a sedative for a client with severe hypothyroidism. The nurse plans to contact the provider to review the safety of the prescription for the client and consults first with the charge nurse. The charge nurse notes that the prescription is written legally and completely. How should the charge nurse respond? A. Affirm the nurse’s plan to review the prescription with the provider. B. Offer to administer the proscription since the nurse has concerns. C. Advise the nurse to administer the medication as prescribed. x D. Assume responsibility for discussing the concern with the provider. -thuốc Hypothyroidism ko được uống chung với thuốc sedative 20/ The nurse-manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern? A. Employee’s job security. B. Potential changes in employee benefits. C. Changes in job descriptions. D. New management’s expectations. 21/ An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? A. Bring the client to the team meeting to discuss the treatment plan. B. Play a broad game with the client and begin talking about stressors. (QL) C. Explain the purpose of each medication the client is currently taking. D. Ask the client to write feelings in a journal and then review it together. 22/ Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly? A. Antiembolism stockings on, leg exercises performed hourly. (Hero) B. Antiembolism stockings removed hourly during leg exercises. C. Leg exercises not performed because of placement of antiembolism hose. x D. Client demonstrates ability to move all extremities well. x 23/ An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which intervention should the nurse implement first? (please scroll and view each tab’s information in the client’s medical record before selecting the answer.) A. Initiate continuous dopamine infusion at 2 mcg/kg/minute. = Inotropic for low BP, low HR, cardiac arrest B. Begin potassium chloride 10 mEq over 1 hour per secondary infusion. = for vomit and diarrhea long time C. Give a bolus of 0.9% sodium chloride 1,000 mL over 30 minutes. = for dehydration, loss water D. Administer promethazine 25 mg slowly IV push every 4 hours. = antihistamine Patient low potassium 2.5 => give potassium 24/ A male client who has been diagnosed with schizophrenia is withdraw, socially reclusive, and answers questions with one or, two-word responses. This morning the nurse notes that he is diaphoretic and is pacing in the hallway. Which intervention is most important for the nurse to implement? A. Take the client’s temperature and blood pressure. B. Encourage the client to rest. C. Plan an activity that includes physical exercise. D. Carefully observe the client during the shift. 25/ The nurse is preparing a hepatitis teaching program. Which individual has the greatest need for teaching about prophylactic hepatitis B immunizations? A. A salesperson who travels internationally and eats food in foreign countries. B. A child daycare worker who has a history of Type 2 diabetes mellitus. C. A restaurant chef who was diagnosed one year ago with hepatitis A. D. An office worker who requires hemodialysis for chronic kidney disease (CKD). 26/ The nurse is planning to administer two medications to a client at 0900. which property of the drugs, if shared by both drugs indicates a need to closely monitor the client for drug toxicity? A. Short half-life. B. High therapeutic index. C. Highly protein bound. D. Low bioavailability. 27/ When conducting diet teaching for a client who was diagnosed with hypertension, which foods should the nurse encourage the client to eat? (Select all that apply.) A. Pickled olives. x B. Canned soup. x C. Fresh or frozen vegetables without sauce. D. Fruits without sauce. E. Cottage cheese. x 28/ A client receives codeine for pain every 4 to 6 hours over 4 days. Which assessment should the nurse perform before administering the next dose? A. Auscultate the bowel sounds. B. Palpate the ankles for edema. C. Observe the skin for bruising. D. Measure the body temperature. Narcotic opioid analgesics => constipation 29/ An adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hours. The pharmacy delivers 10 million units/liter of normal saline. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) - Answer: 83 (2*10/24) 30/ A client presents to the clinic with concerns regarding her left breast. Which assessment finding is most important for the nurse to report to the healthcare provider? A. Multiple firm, round, freely movable masses. B. A slight asymmetry of the breasts. C. A fixed nodular mass with dimpling of skin. (QL) D. Bloody discharge from the nipple. 31/ A male client with heart failure becomes short of breath, anxious, and has audible wheezing with pink frothy sputum. The nurse sits the client upright and provides oxygen per nasal cannula. The nurse receives a prescription to administer a one-time dose of morphine sulfate intravenously. What action should the nurse take? A. Consult with the charge nurse regarding the morphine prescription. x B. Administer the dose of morphine sulfate as prescribed. C. Withhold the morphine until the client’s dyspnea resolves. D. Review the need for the prescription with the healthcare provider. 32/ The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using a Medela Haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple’s elongated tip in the back of the oral cavity. Which instructions should the nurse provide the mother about feedings? A. Position the baby in the left lateral position after feeding. B. Squeeze the nipple base to introduce milk into the mouth. C. Hold the newborn in an upright position. (QL) D. Alternate milk with water during the feeding. 33/ The nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The client with which condition should be assigned the only private room available? A. Bacterial meningitis. (QL) B. Brain abscess. C. Viral encephalitis. D. Septic shock. 34/ A client with a C-6 spinal cord injury is in rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or “goose bumps”. The nurse should assess for which trigger? A. Frequent cough. B. Full bladder. C. Fever. D. Loud hallway noise. 35/ A client at 42-weeks’ gestation arrives at the labor and delivery unit for scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a “natural” delivery. Which action is most important for the nurse to implement? A. Discuss alternative ways to support the client’s birth plan. B. Explain the indications for induction related to post-term pregnancy. C. Discuss the character of labor from endogenous vs exogenous oxytocin. D. Ask the healthcare provider to discuss the issue with the client. 36/ An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HTN), is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments should the nurse include in evaluating the effectiveness of the medications? (Select all that apply.) A. Bowel sounds. B. Heart sounds. C. Blood pressure. D. Daily weight. E. Range of motion. 37/ A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. What instruction should the nurse provide to this mother? A. Withhold this dose. (QL) B. Mix the next dose with food. C. Give another dose. D. Administer a half dose now. Digoxin toxicity = anorexia, nausea, vomiting and neurological symptoms => withhold 38/ An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement? A. Ask family members to remain with the client in the evening from 1700 to 2100 p.m. B. Postpone administration of nighttime medications until after 2300 p.m. C. Administer a prescribed PRN benzodiazepine at the onset of a confused state. = CNS depression D. Ensure that the client is assigned to a room close to the nurse’s station. (QL) 39/ Which instruction should the nurse delegate to unlicensed assistive personnel (UAP)? A. Call the pharmacy to obtain a client’s next antibiotic dose. B. Bring a sterile chest drainage unit from central supply to the unit. C. Observe a client’s gait to determine the need for assistance. D. Evaluate a client’s urinary catheter for proper drainage. 40/ A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client’s nipples are inverted. Which action should the nurse implement? A. Recommend using a breast shield. (QL) B. Encourage the use of ice on the areola. C. Teach about the use of a breast pump. D. Offer supplemental formula feedings.