HESI RN EXIT EXAM COMPREHENSIVE V1-2025 ACTUAL EXAM

1. The nurse is reviewing medical prescriptions for newly admitted clients. It would be a priority for the nurse to follow up with the physician if a client with a. A potassium of 4.5 mEq/L has Kayexalate (sodium polystyrene) prescribed b. 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 a URI (upper respiratory tract infection) b. …old, has type 1 Diabetes Mellitus, and a recent Hemoglobin A1c of 1… c. 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and employed as a mail carrier d. 70 years old, has schizophrenia, lives alone and reports hearing non-threatening voices. 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 a positive Babinski reflex b. 4 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 first assess the client who has: a. Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90% b. Parkinson’s Disease and is demanding to leave the hospital against medical advice (AMA) c. Guillain Barre Syndrome and has begun plasmapheresis therapy d. Heart Failure (CHF) whose pitting edema has increased to 2(+) e. Retinal detachment and is complaining of dark floating spots 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. Ambulating a post-op patient for the first-time d. Performing a 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 d. Reviewing a clients lab values with the nutritionist 10. 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 day room 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 refuse to 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 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. The nurse 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 first check the client who a. Had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours after the indwelling catheter is removed b. Has cervical traction and is moving the legs by flexing 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. history of partial seizures and is sitting in the bed picking at the clothing and smacking… 14. The nurse in a community health clinic is talking with the parent of a child with Celiac Disease. Which of the following statements would require follow-up by the nurse for additional teaching? a. “This weekend we are going to a seafood restaurant” b. “I can feed my child oatmeal and eggs for breakfast” c. “My child loves to eat rice and chicken for dinner” d. “Last night we ate fish with corn for dinner” 15. The charge nurse is observing a Licensed Practical Nurse (LPN) performing care for assigned clients. Follow up will be required if the LPN: a. Assesses a client’s apical pulse for 60 seconds before administering Digoxin b. Completes an incident report for a client that has a pair of eyeglasses missing c. Dons a clean glove on the dominant hand before tracheal suctioning d. Positions a client on the operative side following a pneumonectomy 16. The nurse at a health promotion fare has taught a group of parents about car seat and seat belt safety. Which of the following statements, if made by the parent, would indicate a correct understanding of the information given? a. “I will place my newborn infant in a rear facing car seat in the middle of the rear seat.” b. “I will wear a lap seat belt high on my belly since I am 8 months pregnant.” c. “I can use a front-facing car seat once my baby weighs 15 pounds.” d. “I can allow my six-year-old to use a seat belt in the front passenger seat” 17. The nurse is caring for a client being treated for Vancomycin Resistant Enterococcus (VRE). The nurse should place the client on a. Contact precautions b. Droplet precautions c. Protective precautions d. Airborne precautions 18. The nurse is caring for a client with a Vancomycin Resistant Enterococcus (VRE) wound infection. Which of the following actions would be appropriate for the nurse to take? a. Wear a particulate respirator mask when providing wound care b. Instruct visitors not to bring flowers into the client’s room c. Place the client in a private room with negative air pressure d. Wear a disposable gown when changing the client’s dressing 19. The nurse should initiate protective precautions for a client who has a a. Red Blood Cell Count (RBC) of 3,900/mm3 b. Platelet count of 400,000μ/L c. Hemoglobin (Hgb) 9.0 g/dl d. White Blood Cell Count (WBC) 2,500/mm3 20. The nurse has provided health promotion teaching for a group of clients who were recently diagnosed with the Human immunodeficiency virus (HIV). Which statement, if made by one of the clients, would require further teaching? a. “I am glad that I can still clean my parakeet’s cage” b. “I will not go to the parade this weekend” c. “I will increase protein in my diet” d. “I will miss not being able to work in my garden 21. The nurse in the emergency department is caring for disaster clients admitted following a rescue from a burning bus. The nurse should first see the client who a. Has the tibia bone protruding through the skin and is in severe pain b. Has third degree burns of the left foot and is crying c. Is unconscious, pulseless, and has dilated pupils d. Has soot on the face and the nares and is coughing 22. A nurse is observing a newly hired nurse provide care for assigned clients. The nurse should follow up if the newly- hired nurse is observed a. Wearing gloves when taking the blood pressure of a client with disseminated varicella zoster b. Cleansing the wound from the outer surface to the inner surface for a client whose wound is infected with a multi- drug resistant organism c. Opening the flap away from the body of a sterile package first. d. Removing the gloves before removing the gown when leaving a room of a client who is on contact precautions 23. The nurse is caring for a client who has been diagnosed with rheumatoid arthritis. The nurse should anticipate that the client will initially be prescribed a. Nonsteroidal anti-inflammatory drugs (NSAIDs) b. Disease-modifying rheumatic agents c. Biologic Response Modifiers d. Long-term corticosteroids 24. The nurse is assessing a 2-month-old-infant at a well-baby clinic. The nurse should anticipate the infant should a. Have no head lag b. Have no tonic neck reflex b. Roll from prone to back c. Smile socially 25. The nurse is teaching a class on infant nutrition. The nurse should instruct parents to introduce a. Fruit juices at 3 months b. Honey sweetened water at 5 months c. Pureed chicken at 7 months d. Whole milk at 9 months 26. The nurse is caring for a 7-year-old who has thrombocytopenia and is on protective precautions. Which of the following would be an appropriate toy for the nurse to provide to the client? a. Finger paints and paper b. A rubber ball and bat c. A board games d. A stuffed toy 27. The nurse on a pediatric unit has been informed that the following clients are being admitted. The nurse should first plan to assess the client who is a. 2 years old, has a temperature of 100.8 F and a blood pressure of 68/44 b. 4 years old with a history of asthma and has a peak expiratory flow rate (PERF) of 81% c. 5 years old, has a fracture of the tibia and is reporting pain rated 7 on a pain scale of 0 (no pain) to 10 (severe pain) d. 7 years old with ulcerative colitis and has had 15 bloody tinged stools today 28. The nurse is assessing a 3-year-old during a well-child visit. During the visit the boy says to his mother, “Mommy, I love you. I’m going to marry you”. The nurse should a. Suggest to the mother not to encourage these types of statements b. Explain to the child that he will not be able to marry his mother even though he loves her c. Tell the mother that this statement is appropriate for his stage of development d. Recommend that the mother provide more opportunities for her son to play with other 3- year-old boys 29. The mother of an infant tells the nurse that the baby has not been tolerating feedings lately and she noticed an olive-shaped mass in the infant’s abdomen. The nurse recognizes that this could be an expected finding if the infant has a. Intussusception b. Hirschsprung’s disease c. Umbilical hernia d. Pyloric stenosis 30. The nurse is teaching a group of parents about the expected growth and development of three-year-old children. The nurse should include that a three-year- old should a. Discriminate between fantasy and reality b. Ride a tricycle independently c. Have a vocabulary of 7,000 words d. Play in a group of two or three with one being the leader 31. The nurse and the nursing assistant are caring for a group of clients. Which of the following client care activities should the nurse assign to the nursing assistant? Select all that apply. a. reinforcing the dressing of a client who has a decubitus ulcer b. monitoring the vital signs of a client who had a myocardial infarction 12 hours ago and is being transferred from the coronary care unit c. administering a tap water enema to a client who will undergo a colonoscopy in two hours d. placing a client who had an above the knee amputation 24 hours ago in a prone position e. assisting a client who had a colon resection 36 hours ago to ambulate f. showing a client who had a vaginal hysterectomy 36 hours ago how to perform perineal care 32. The nurse has become aware of the following client situations. The nurse should first assess the client who a. Had received a unit of packed red blood cells four hours ago and is requesting a bedpan b. Had an abdominal hysterectomy yesterday and is reporting calf pain c. Has history of multiple sclerosis and is reporting diplopia d. Had a tonsillectomy three hours ago and is reporting a sore throat 33. The primary health care provider has prescribed Heparin 5000 units SC. The drug available is heparin sodium 7500units/ml. Choose all of the correct answers for nursing considerations for the administration of heparin sodium. a. administer the heparin in the abdomen b. administer 0.5ml of heparin sodium c. aspirate after inserting the needle d. use a 1 inch 21-gauge needle e. refrain from massaging the site after administer heparin f. remember that protamine sulfate is the antidote for heparin 34. The nurse has attended a staff development conference on cultural considerations for clients receiving hospice care. Which of the following statements if made by the nurse would require follow-up? a. The family of a client of the Buddhist faith may ask for a priest to be present at the time of death b. The family of a client of the Jewish faith may request to stay with the body after the death of the client c. The family of a client of the Muslim faith may request that the body of the client be turned to face the East at the time of the client’s death d. The family of a client of the Hindu faith may request that the client’s body be bathed by staff after the client’s death 35. The nurse is caring for a client with bipolar disorder who has lithium prescribed. The nurse should suggest that the client have which of the following snacks? a. A fresh fruit cup b. Coffee and oatmeal cookies c. Tuna fish salad on saltine crackers d. Raw vegetables 36. The nurse has provided discharge instructions for a client who has been prescribed digoxin (Lanoxin). It will require follow up by the nurse if the client says a. “I will consult my primary health care provider before taking medications that contain aspirin.” b. “I will not take any antacids within two hours of taking the digoxin.” c. “I will avoid fruits such as avocados, grapefruit and cantaloupe.” d. “I will remember that any visual disturbance can be a sign of digitalis toxicity.” 37. The nurse is caring for a client who has bumetanide (Bumex) prescribed. The nurse should suggest that the client include which of the following foods in the diet? a. Apricots b. Organ meats c. Sardines d. Fish 38. The nurse is providing teaching for a client with ulcerative colitis. Select all of the following that the nurse should include in the teaching a. steatorrhea commonly occurs or excessive secretion of fecal lipids is common b. ulcerative colitis occurs most frequently in Jewish males 30- 50 years of age c. a diet in high in residue and low in complex carbohydrates is helpful in controlling symptoms d. corticosteroids may be prescribed during an exacerbation e. metronidazole (flagyl) and ciprofloxacin (cipro) are antibiotics commonly used during acute exacerbations f. eating small frequent meals and lay down after eating promotes absorption of nutrients