HESI Exit Exam 10 Graded A+ 2025

1. Male client admitted the morning of scheduled surgery told nurse he drank water last night. Amount of water and what time was taken. 2. Why would nurse apply pressure to lacrimal duct after optic meds. Reduce systemic effects. 3. Comatose patient mouth care. Side lying position. 4. morning care client have seizure. Protect Pt head. 5. Charge nurse assign PN. Insulin injections. 6. 2 doses missing. Complete report. 7. Pt on suicide ask about discharge. Increases suicide precautions. 8. Photo of chest and locating apical HR. Just below left nipple. 9. At the end of 12hr shift the nurse observes the urine in a client’s drainage. Most recent white blood count. 10. Male client diagnosed with schizophrenia is withdrawn, isolates himself, with one- or two- word responses. Measure appropriate vital signs. 11. 8-year-old on 90-90 traction for a fractured femur. Weights are touching the foot of the bed. 12. Nurse reviewing diet instructions with female client who has hyper and increased her intakes of protein and calories. Continue dietary changes she has made. 13. Discontinue IV therapy infusing at 150ml per hour at 1200 the PN notes that there are 750ml of solution remaining. 1700. 14. The PN is caring for a client who had a total laryngectomy, left radical neck dissection... Client is receiving nasogastric tube feedings via an internal pump. Today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding? Gastric residual volumes. 15. A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take? Ensure that all the areolar tissue of the nipple is in the infants mouth. 16. Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? Deltoid. 17. A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort? Wear a supportive bra at all times. 18. A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client “This type of hospital" what intervention should the PN implement. Act as the clients advocate when discussing the issue with the HCP. 19. A client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the PN implement in response to the clients refusal. Emphasize the importance of active foot flexion. 20. A client recovering from a stroke is learning how to use a cane. How should it be placed. On the stronger side of the body. 21. A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client. Measure all emesis accurately. 22. On admission to the medical unit a client who is homeless and has a history of HIV with persistent cough? Erythema and indurations of 5mm at site 23. When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given in the computer. What action should the PN take. Contact the medication nurse to clarify the findings 24. The PN is implementing the plan of care for a client who admits having...indicates the highest risk for the client acting on these suicidal thoughts. Begins to show signs of improvement. 25. The PN observes that a male clients urinary catheter drainage tubing is...the attached to the bed frame. What action should the PN implement? Observe the appearance of the urine in the drainage tubing. 26. A clients chief complaint is being able to swallow only small bites of solid food...PN should assess for what additional information? History of alcohol and tobacco use. 27. When the PN plans daily care for a group pf clients, which client should the PN see first due to the risk of complication? An older client with a stroke who is febrile and confused. 28. When entering the room of an older female resident of a long-term care facility, the PN finds one of the male residents in bed with her. What action should the PN take. Close the door and report the finding to the charge nurse. 29. Prior to giving digoxin, the PN assesses that a 2-month-old infants heart rate is 120 beats/min. Based on this finding what action should the PN take. Give the medication and document the heart rate. 30. A client reports feeling numbness and tingling in extremities. What action should the PN implement. Review the clients serum electrolyte levels. 31. A 0800 a clients apical pulse rate is 98 beats/minute> Four hours later the apical pulse rate is 54 beats/minute. What action should the PN take next. Determine the level of consciousness. 32. A 5-year-old child is admitted with full thickness burns over 30% of the total body surface areas (TBSA). After fluid replacement therapy is initiated, which finding should the PN use to evaluate the effectiveness of the therapy. Urine output. 33. Direct Coombs' test newborn Positive. Administer Rh immune globulin. 34. When repositioning patient, the nurse observes wound with a foul odor the nurse should. Check the white blood cell count. 35. Prior to administering a prescribed tube feeding to a client with a gastrostomy tube why would the practical nurse aspirate for gastric residual volume. The evaluate the amount of gastric emptying. 36. Admin oxygen to infant with Tetralogy of Fallot nurse intervention. Hold in knee to chest position. 37. Client report numbness and tingling what lab values should the nurse check. Electrolytes. 38. Client cough and spit large amount of frothy saliva for sputum collection. Reteach client cough techniques. 39. Homeless male with history of alcohol abuse, CVA accident, presents with edema and pain in left leg. 40. Inspect leg for infection or trauma. 41. Mother wants to take 9-month-old infant with RSV to birthday party. Don’t expose other children virus is contagious 42. PICTURE urine bag. Note latest WBC or check finger glucose. 43. Instrument obtained for Weber test. Tuning fork. 44. Mother breast feeding for first time reports nipple pain when baby suck. Ensure nipple is in infants mouth. 45. PICTURE bp cuff. Demonstrate how to palpate a brachial pulse. 46. Elderly man wakes and wanders at 3:30am. Address client to determine needs. 47. 5yr old with otitis externa. Gently pull lobe up and back. 48. Pt has NG tube hooked to sucking after admin meds. Clamp tube for 30min after meds. 49. 24hr infant regurgitate nurse should. Suction oral and nasal passage 50. Female client has hemorrhoids that are flamed and hurt constantly. Position client in left lateral position inspect the perineal area. 51. Daughter claims mother was mistreated overnight. Ask for description of what happened 52. PICTURE prepares to suction oropharynx Initiate intermediate suction. 53. Pt has truncal obesity, buffalo hump, and moon face. Corticosteroids. 54. Single mother in room crying with child can’t cope. Recommend that she stays calm and positive. 55. Client receives 20 units of insulin, 4hr later becomes shaky and diaphoretic. Give milk and crackers. 56. Male college student roommate hears voices saying kill. Are you planning to obey these voices? 57. Total laryngectomy, what parameters should nurse take to evaluate feeding. Gastric residual volume. 58. 10 year old diabetic, important question for nurse to ask. Did you perform a fingerstick? 59. UAP can work with (SATA). -daily skin care -morning care -toileting 60. Place in order. -ruptured appendix. -severe headache. -wandering. -discharge instruction. 61. Client receiving antibiotic for infection, report. Hives with pruitisis. 62. Client receiving Fentanyl for pain. Recommend foods high in fiber. 63. Which preop Pt require immediate care. Following the suture removal, the wound dehiscence. 64. Glascow coma scale nurse should evaluate. LOC. 65. Adult client with 40% burns should report. Urine output of 20ml. 66. Wheelchair bound elderly person activity. Group ring toss competition. 67. Focused assessment for young adult nutritional status. 24hr diet history. 68. Applying hand sanitizer. Place one hand on top of another and intertwine them. 69. Following a total hip replacement. Keep hips aligned with knees abducted. 70. 8yr old in 90-90 traction for femur fracture, require further action. Weights touching foot of bed. 71. Compound fracture left ankle with below the knee cast discharge teaching. Never scratch under the cast. 72. Client with cirrhosis experiencing peripheral neuropathy. Protect client from injury. 73. T1N0M0 stands for -tumor size -node involvement -metastasis 74. Instruct postpartum Pt to report. Sudden or persistent temp of 100.5. 75. Severely depressed client exhibits. Disorder of sleep. 76. Small fire breaks out in kitchen, nurse should. Method of transport and evaluate. 77. PICTURE place X on apical heart rate. 5th intercostal space. 78. Assessment finding for client with pneumonia SATA. -lung crackles -dyspnea -painful cough 79. 3yr old have minor surgery. Point to nose and say nose. 80. 20yr old with history of tobacco complains of difficulty swallowing and dyspnea, what other finding Hoarse voice. 81. LPN and UAP find unresponsive Pt, UAP should. Obtain emergency help. 82. Pt has fistula, complains of palpable buzzing sensation, nurse should. Loosen fistula dressing or document. 83. Client receives new prescription at 1000, discontinue IV antibiotic, what to give at 1300. Ampicillin 500mg. 84. PICTURE radial pulse. Teach UAP correct site for radial pulse. 85. Pregnant women with anemia teaching (SATA). -eat more beans. -add leafy green vegetables. -oatmeal 86. PICTURE applying sequential compression device. Under closest to ankle. 87. Child admitted for tonic clonic seizure, nurse should implement what at next episode (SATA). -hold extremities close to the body. -pad side rails. -observe progression of seizure 88. Older male client takes psychotropic meds, has uncontrollable movements. Screen for tardive dyskinesia. 89. New mother with engorged breast. Wear supportive bra at all times. 90. Native American female has medication wheel dr. Doesn’t approve, nurse should. Act as clients advocate. 91. Pt with acute kidney injury has abnormal labs, high bp, etc. Nurse should. Monitor for dependent edema. 92. A female client takes herbs instead of the pre hypertensive meds. Inform Pt of the risk. 93. Difficulty breathing is related to what part of the brain being injured. Medulla. 94. Following cardiac catheterization, nurse should report. Faint pedal pulses. 95. Nurse preparing to transfer Pt to chair, who requires assistance. Pt impaired cognition and agitated. 96. Turning a dependent bedridden Pt, to ensure safety. Put bed rails up on opposite side. 97. 18yr old female with mild mental disability, best response. I’ll be back in 30min to help you ambulate. 98. One day postop of appendectomy, complains of tightness and SOB. Have client sit down in hallway. 99. Laryngectomy, left radial neck dissection. Perform routine stoma/suture care. 100. Tingling sensation of nose, fingertips, ear lobe 24hr after thyroidectomy. Give calcium gluconate. 101. Nurse should see who first due to risk of complication. Older adult Pt who is febrile and confused. 102. Oil retention enema regarding temp. Clients body temp. 103. Cocaine withdrawals. Powerful craving for more. 104. Suicidal Pt at greatest risk. Shows signs of improvement. 105. 25yr old in active labor, two-year-old at home. -Grava 2 -para 1 106. Can’t feel fundus and large amount of blood. Empty bladder. 107. Distraction techniques Think of past family event 108. Bone marrow aspiration site Posterior iliac crest 109. Female unproductive cough bp 108/58, r 22, p 94 Notify charge nurse 110. Nurse notices erythema on right hip Change position every 2hrs 111. Remove saline lock (SATA): -exam gloves -3ml syringe -gauze -tape 112. Ondansetron before chemo. Monitor for nausea and vomiting 113. Emptying a hemovac drain PUT IN ORDER -apply gloves -remove drainage -compress -lock plug 114. The LPN/LVN is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation? Premedicate the client with an analgesic before ambulating. 115. A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which first? Check the client status and lead placement. 116. The LPN/LVN in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. -Administering oxygen -Inserting a Foley catheter -Administering furosemide (Lasix) 117. The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? Status of airway. 118. The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? Limiting movement and abduction of the right arm. 119. A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The LPN/LVN understands that a life- threatening complication of this condition is which? Pulmonary embolism. 120. A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? Smoking history. 121. The nurse has reinforced instructions to the client with Raynaud's disease about self- management of the disease process. The nurse determines that the client needs further teaching if the client states which? "Moving to a warmer climate should help." 122. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? Crackles. 123. The LPN/LVN is collecting data on a client with a diagnosis of right- sided heart failure. The nurse should expect to note which specific characteristic of this condition? Dependent edema. 124. The LPN/LVN is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which? Normal, caused by increased blood flow through the leg. 125. A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The LPN/LVN responds that this procedure may stimulate which? Vagus nerve to slow the heart rate. 126. A client is admitted to the hospital with possible rheumatic endocarditis. The LPN/LVN should check for a history of which type of infection? Staphylococcal infection. 127. client has an Unna boot applied for treatment of a venous stasis leg ulcer. The LPN/LVN notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? The boot has been applied too tightly. 128. A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the LPN/LVN best describe this type of anginal pain? Variant angina. 129. The LPN/LVN is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? Hyperactive bowel sounds in the area. 130. An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response? Denial. 131. A client is scheduled for a cardiac catheterization using a radiopaque dye. The LPN/LVN checks which most critical item before the procedure? Prior reaction to contrast media. 132. A client is scheduled for a dipyridamole thallium scan. The LPN/ LVN should check to make sure that the client has not consumed which substance before the procedure? Caffeine. 133. An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a non-cardiac problem? "Does the pain get worse when you breathe in?" 134. A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? Bathroom privileges and self-care activities. 135. The LPN/LVN is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? Surgical tourniquet. 136. A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated? Bed rest, with elevation of the affected extremity. 137. A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client? With the foot of the bed elevated. 138. The LPN/LVN is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? Bilberry. 139. The LPN/LVN is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. -Be careful not to injure the legs or feet. -Walk each day to increase circulation to the legs. -Cut down on the amount of fats consumed in the diet. 140. A client is at risk for developing disseminated intravascular coagulopathy (DIC). The LPN/LVN should become concerned with which fibrinogen level? 90 mg/dL. 141. A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The LPN/LVN should take which action first? Assist the client to sit or lie down. 142. The LPN/LVN notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action? Reviews the intake and output records for the last 2 days. 143. A client brings the following medications to the clinic for a yearly physical. The LPN/LVN realizes which medication has been prescribed to treat heart failure? Digoxin (Lanoxin). 144. A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? Restricting the client's potassium intake. 145. A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcing when teaching the client?