HESI Exit Exam 4 Graded A+ 2025

1. The practical nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the PN to take? Wait for the client to excuse himself from the telephone conversation and observe the client taking the medication. 2. A client is admitted to the postoperative surgical unit with two test tubes after a left lobectomy. The ON observed that the chambers are set at the prescribed suction of 20 cm water pressure and tidying occurs with respirations and bubbling. What action should the PN implement? Maintain system integrity to promote lung expansion. 3. The mother of a 9-month-child who was diagnosed with respiratory syncytial virus yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child for the following day. Which response should the PN provide the mother? Do not expose other children as the virus is very contagious even without direct contact. 4. The practical nurse is assisting the nurse with the admission of a young adult female Korean exchange student with acute abdominal pain. Although the client has been able to easily answer questions, when asked about sexual activity, she looks away. What action should the PN take? Watch the client's response when asked a different question. 5. During immediate postoperative period following a total hip placement, which intervention is most important for the PN to implement? Keep client's hip aligned with knees abducted. 6. A client confides to the PN that the client has been substituting herbal supplements for high blood pressure instead of the prescribed medication. How should the PN respond first? Ask the client's reason for choosing to take herbs instead of prescribed drugs. 7. The PN is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. What is the best nursing action for the PN to take prior administering the medications this resident? term-14 Confirm the room and bed numbers with those on the medication record. 8. An adult client who weighs 150 pounds has partial-thickness and full-thickness burns over 40% of the body from a house fire. After admission, which observation is most important for the practical nurse to report immediately? Urinary Output of 20ml/hr. 9. A 12-year-old child is receiving a blood transfusion per infusion pump and begins to complain of "itchy" skin 15 minutes after the unit of blood is started. The child appears flushed. What action should the practical nurse take first? Stop the transfusion. 10. A PN is competing a focused assessment of an older adult's skin. The PN notes a crusted 0.7 cm lesion on the client's forehead. Which action should the PN take in response to this finding? Apply a warm compress to remove the crusted area. 11. While taking the vital signs of an older male client who takes psychotropic medications, the PN notes that he has uncontrollable hand movements and is excessively blinking his eyes. Which information in the client's medical record should the PN review? History of Parkinson's disease. 12. The PN is caring for an elderly female client who tells the PN, "When I sneeze, I wet my pants." After discussing the client's complaint with the charge nurse, the PN plans to reinforce teaching that the client has received about the importance of Kegel exercises. What muscles are involved in these exercises? Pelvic floor muscles. 13. While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement? Use oral swabs with normal saline. 14. The practical nurse and unlicensed assistive personnel are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement? Demonstrate to the UAP how to approach the client from the client's left side. 15. After administering pantoprazole to a client with gastroesophageal reflux disorder (GERD), which statement by the client indicates to the practical nurse that the medication is producing the desired effect? After eating my meal, I did not experience any heartburn. 16. During the last 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of daytime hours in bed and refuses to participate in planned daytime activities. Which action should the practical nurse take? A. Record the findings and report the symptoms to the charge nurse. 17. A male client who has been diagnosed with schizophrenia is withdrawn, isolates himself in the day room, and answers question with one- or two-word responses. This morning, the practical nurse observes that he is diaphoretic and is pacing in the hall. Which intervention is most important to the PN to implement? Measure appropriate vital signs. 18. At 1200, the practical nurse learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take? Administer the missed dose as soon as possible. 19. The practical nurse is caring for a client who had a total laryngectomy, left radical neck dissection, and tracheostomy. The client is receiving nasogastric tube feedings via an enteral pump. Today the rate of feeding is increased from 50 ml/hr to 75 ml/her. What parameter should the PN use to evaluate the client's tolerance to the rate of the feeding? Gastric residual volumes. 20. The practical nurse is caring for a client whose urine drug screen is positive for cocaine, which behavior is this client likely to exhibit during cocaine withdrawal? Powerful craving for more. 21. The PN administered darbepoetin alfa to a client with chronic kidney disease (CKD). Which serum laboratory value should the PN monitor to gather the effectiveness of this drug? Phosphorous. The PN observes an UAP bathing a bedfast client with the bed in the high position. Which action should the PN take? Instruct the UAP to lower the bed for safety. 22. Thirty minutes after receiving IV morphine, a postoperative client continues yes to rate pain as 7 on 10-point scale. Which action should the PN implement first? Implement complimentary pain relief methods. 23. The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was 0 station. An hour later, the client tells the PN that she wants to go the bathroom. Which action is most important for the PN to implement? Request nurse to check client's cervical dilation. 24. The PN identifies an electrolyte imbalance, exhibited changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first? Evaluate for muscle cramping. 25. The PN is caring for an older client who was informed about the diagnosis of terminal cancer two days ago. Which intervention would be most helpful for the client's spouse at this time? Information about palliative and hospice care services. 26. The PN is caring for a child who was admitted after experiencing a generalized tonic-colonic seizure. When witnessing the child begin to seize again, which actions should the PN implement immediately? Select all that apply -Observe the progression of the seizure -Loosen clothing around the neck -Pad the side rails with pillows 27. The HCP prescribes heparin 4,500 units subcutaneously once daily. The medication is available in a vial that contains heparin 10,000 units/mL. How many mL should the PN administer? 0.45 28. The UAP is caring for a male resident of a long-term care facility who has an external urinary catheter. Which finding should the PN instruct the UAP to report immediately? Swollen and discolored menial shaft. 29. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the PN implement? Suction the oral and nasal passages. 30. A client reports being able to swallow only small bites of solid food and liquids for the last 3 months. The PN should assess the client for what additional information? History of alcohol or tobacco use. 31. When caring for a child with sickle cell disease, the PN expects that the child will most likely describe which symptom when experiencing a sickle cell crisis? Fatigue. 32. At the first dressing change, the PN tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best? Part of recovery is accepting your new body image, and you will need to look at your incision. 33. A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coomb's test. Which is the implication of this finding? The mother's Rh antibodies are present in the neonatal serum. 34. During a clinic visit for a sore throat, a client's basal metabolic panel reveals a serum potassium of 3.0 mEq/L. Which intervention should the PN recommend to the client based on this finding? Increase intake of dried peaches and apricots. 35. The PN is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client replies that the cloth used to anesthetize the eye if eye pain is experienced. What action should the PN implement? Explain to the client that they eye drops do provide pain relief, but do not anesthetize the eyes. 36. The PN is reviewing care instructions with a client who has diabetic retinopathy and is experiencing glare around lights. What should the PN reinforce with the client? Make adjustments to personal schedule to avoid driving at night. 37. The PN is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the UAP? Select All That Apply Empty bedside drainage unit for a client with indwelling urinary catheter. Obtain a post-voided residual volume. 38. A client on bedrest refuses to wear the prescribed pneumatic compression devices after surgery. Which action should the PN implement in response to the client's refusal? Emphasize the importance of active foot flexion. 39. The PN is caring for a client who had an acute brain attack with resulting expressive aphasia and urinary incontinence. To ensure care for the client, which task should the PN delegate to the UAP? Encourage voiding by assisting client to bedside commode. 40. When reinforcing diet teaching for a client who was diagnosed with hypokalemia, which foods should the PN encourage the client to eat? Select All That Apply -Orange juice, oranges, bananas. -Collard greens, kale, turnips. -Soybeans, lima beans, spinach. 41. When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma? Stomadhesive. 42. The PN observes an UAP prepare to exit a client's room. The UAP's hands appear visibly soiled as the UAP uses a hand rub for 19 seconds to cleanse the hands. Which action should the PN take? Advise the UAP to use the hand rub for 30 seconds. 43. A male client with TB returns to the clinic for daily antibiotic injections for a urinary infection. The client has been taking anti tubercular medications for 10 weeks and states he has ringing in his ears. Which prescribed medication should the PN report to the HCP? Gentamicin 160 mg IM daily. 44. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The PN notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement? Ensure that the client is assigned to a room close to the nurses' station 45. Which action should the PN implement when using standard precautions to provide client care? Wear clean exam gloves to perform perineal catheter care. 46. When administering an analgesic to a client with low back pain, which intervention should the practical nurse implement to promote the effectiveness of the medication? Encourage the client to ambulate frequently and take deep breaths. 47. A young adult male tells the PN he has decided to change his hours at work so that he has more time to devote to his community. Which stage of Maslow's development is this young adult attempting to achieve? Self-Actualization. 48. The PN assigns an UAP to bathe a client who is on contact precautions due to Clostridium Difficult maintain contact precautions, the PN should instruct the UAP to perform the following actions in which sequence? -Perform standard hand washing -Put on disposable gown -Don a pair of procedure gloves -Remove gloves and gown in room -Repeat standard hand washing 49. The single mother of a child with a head injury is sitting at the child's bedside crying when the PN enters the room. The mother states, "Why did this happen to my child? I just can't cope with this." How should the PN respond? Express that the present situation must be overwhelming. 50. While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the PN implement first? Have the client sit down in the hall. 51. The PN is assigned to care for an older male client who is recovering from a stroke. When assisting this client to ambulate with the use of a cane, where should the PN place the cane in relation to the client's body? On the same side as the affected extremity. 52. A client is scheduled to receive hydroxyzine 75 mg IM postoperatively. The vial contains 50mg/mL. How many mL should the PN administer? 1.5 53. Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his progress? I've found support I need from my faith and family. 54. In obtaining an orthostatic vital sign measurement, what action should the nurse take first? Instruct the client to lie supine. 55. A female client tells the PN that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the PN to implement to complete a focused assessment? Ask the client how long she has experienced discomfort related to hemorrhoids. 56. A client who is receiving chemotherapy has developed stomatitis. Which instruction should the PN provide the UAP who is assisting with the care of this client? Gather supplies for protective environmental precautions. 57. The PN observes an UAP performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the PN take? Tell the UAP to continue because the unconscious client is positioned safely. 58. When preparing for a bone marrow aspiration, the PN should place the client in which position to ensure access of the aspiration site? Prone with the posterior iliac crest draped. 59. Which client information is most important for the PN to consider when providing instructions to the UAP to consider when providing instructions to the UAP about providing morning care to a postoperative client? Blood pressure of 144/84. 60. The PN notes that an older female client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are temperature 99.8 F, pulse 94, respirations 22, and B/P 108/54. Which intervention is most important for the PN to implement? Report the findings to the charge nurse. 61. A male client attends a community support program for mentally impaired and chemical abusing clients. The client tells the PN that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client? Hypertension. 62. The PN notes that an UAP is ambulating a male client who had a stroke and has right-sided weakness. The UAP is walking on the client's left side. Which action should the PN take? Instruct the UAP to walk on the client's affected side. 63. The PN is assisting the nurse with admission physical assessment of a client diagnosed with pneumonia. What symptoms are the client likely to exhibit? Select All That Apply -Dyspnea -Lung crackles -Painful Cough 64. Prior to giving digoxin, the PN assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take? Give the medication and document the heart rate. 65. The PN reviews client's medication history and learns that the client takes an anticoagulant and has recently started taking phenytoin. Which instruction should the PN provide when assigning the client's morning care to an UAP? Protect skin from injury and bruising. 66. The UAP reports to the PN that an assigned client experiences SOB when the bed is lowered for bathing. Which action should the PN implement? Advise the UAP to allow the client to rest before completing the bath. 67. While turning and positioning a bedfast client, the PN observes that the client is dyspneic. Which action should the PN take first? Notify the charge nurse. 68. The PN has added feeding solution to a client's tube feeding system as seen in the picture. Which action should the PN take next? Obtain a piston syringe and irrigation set. 69. Based on the computer documentation in the EMR, which action should the PN implement? Give the rubella vaccine subcutaneously. 70. What intervention should the PN implement when raking the rectal temperature of an adult client? Hold the thermometer the entire time while taking the temperature. 71. Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the PN to ask the child? Did the child perform a finger stick? 72. A female client who has been taking oral contraceptives for the past year comes in the clinic for an annual exam. Which finding is most important for the PN to report to the HCP? Left calf pain. 73. A client takes one 500 mg calcium tablet twice daily. How many grams of calcium is the client taking daily? 1 74. The ON observes a client's initial postoperative dressing and drains as seen in the picture, which follow-up actions should the PN implement? Select All That Apply -Document the appearance of the wound as inflamed. -Report the appearance of the dressing to the charge nurse. 75. At the end of a 12-hour shift, the PN observes the urine in a client's drainage bag as seen in the picture. Which action should the PN take next? Note the most recent white blood cell count. 76. An older male client with Alzheimer's disease is admitted to an extended care facility. Which intervention should the PN include in the client's nursing care plan? A. Plan to have the same nursing staff provide care for the client whenever possible. 77. A female client taking a liquid iron preparation expresses concern that her tooth color has darkened since starting the medication. What action should the PN implement? Reassure the client that this change indicates the medication is having the desired effect. 78. While conducting a mental status examination of a newly admitted male client, the PN notes that his head is lowered, and he shows no emotion or expression when speaking. Based on this observation, what documentation should the PN include? Depressed mood. 79. A client tells the PN that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce her risk of getting cancer. How should the PN respond? Suggest that an increase in fruits and vegetables is more beneficial. 80. A new mother who is breastfeeding her newborn for the first time after delivery reports nipple pain when the baby sucks. Based on this client problem, which action should the PN take? Ensure that all the areolar tissue of the nipple is in the infant's mouth. 81. A homeless male client with a history of alcohol abuse had a CVA 10 years ago that resulted in left hemiparesis. Today he is brought to the clinic reporting pain in his left leg. He is afebrile, has 4+ pitting edema in the lower left leg, and has minimal swelling of the right leg. Which action should the PN implement first? Inspect legs for infection or trauma.