HESI EXIT RN ACTUAL EXAM 100% EXPERTLY
DETAILED ANSWERS solutions and explanations
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all
that apply)
A. Fluid shifts from intravascular to interstitial area due to decreased serum
protein
B. Increased hydrostatic pressure in portal circulation increases
fluid shifts into abdomen
C. Increased circulating aldosterone levels that increase sodium and water
retention
The nurse is auscultating a client's heart sounds. Which description should the nurse use to
document this sound? (Please listen to the audio first to select the option that applies)
Murmur
A 30 month-old child is admitted to the hospital unit. Which of the following toys would be
appropriate for the nurse to select from the toy room for this child?
A) Cartoon stickers
B) Large wooden puzzle
C) Blunt scissors and paper
D) Beach ball
B) Large wooden puzzle
A nurse is to present information about Chinese folk medicine to a group of student
nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the
A) Yang, the positive force that represents light, warmth, and fullness
B) Yin, the negative force that represents darkness, cold, and emptiness
C) Use of improper hot foods, herbs and plants
D) A failure to keep life in balance with nature and others
B) Yin, the negative force that represents darkness, cold, and emptiness
,A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse
"What is our major concern now, and what will we have to deal with in the future?" Which of the
following is the best response?
A) "There is a probability of life-long complications."
B) "Cystic fibrosis results in nutritional concerns that can be dealt with."
C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
D) "You will work with a team of experts and also have access to a support group that the family
can attend."
C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
Which type of accidental poisoning would the nurse expect to occur in children under
age 6?
A) Oral ingestion
B) Topical contact
C) Inhalation
D) Eye splashes
A) Oral ingestion
A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly
bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and
demands constant attention from the staff. Which activity would be best for the client?
A) Reading
B) Checkers
C) Cards
D) Ping-pong
D) Ping-pong
The nurse is caring for a client who has developed cardiac tamponade. Which finding
would the nurse anticipate?
A) Widening pulse pressure
B) Pleural friction rub
C) Distended neck veins
,D) Bradycardia
C) Distended neck veins
Which nursing action is a priority as the plan of care is developed for a 7 year-old
child hospitalized for acute glomerulonephritis?
A) Assess for generalized edema
B) Monitor for increased urinary output
C) Encourage rest during hyperactive periods
D) Note patterns of increased blood pressure
D) Note patterns of increased blood pressure
The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the
following actions by the nurse would be appropriate?
A) Schedule the therapy thirty minutes after meals
B) Teach the child not to cough during the treatment
C) Confine the percussion to the rib cage area
D) Place the child in a prone position for the therapy
C) Confine the percussion to the rib cage area
Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic
drugs?
A) Orthostatic hypotension is a common side effect
B) Most antipsychotic drugs cause elevated blood pressure
C) This provides information on the amount of sodium allowed in the diet
D) It will indicate the need to institute anti parkinsonian drugs
A) Orthostatic hypotension is a common side effect
.
The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity.
Which choice indicates the client understands dietary needs?
, A) Three apricots
B) Medium banana
C) Naval orange
D) Baked potato
D) Baked potato
.
An 86 year-old nursing home resident who has decreased mental status is hospitalized with
pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid
diet, the client begins to cough. What should the nurse do next?
A) Add a thickening agent to the fluids
B) Check the client's gag reflex
C) Feed the client only solid foods
D) Increase the rate of intravenous fluids
B) Check the client's gag reflex
.
The nurse is planning care for a client with a CVA. Which of the following measures planned by the
nurse would be most effective in preventing skin breakdown?
A) Place client in the wheelchair for four hours each day
B) Pad the bony prominence
C) Reposition every two hours
D) Massage reddened bony prominence
C) Reposition every two hours
.
A nurse is assessing several clients in a long term health care facility. Which client is at highest
risk for development of decubitus ulcers?
A) A 79 year-old malnourished client on bed rest
B) An obese client who uses a wheelchair
C) A client who had 3 incontinent diarrhea stools
D) An 80 year-old ambulatory diabetic client
DETAILED ANSWERS solutions and explanations
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all
that apply)
A. Fluid shifts from intravascular to interstitial area due to decreased serum
protein
B. Increased hydrostatic pressure in portal circulation increases
fluid shifts into abdomen
C. Increased circulating aldosterone levels that increase sodium and water
retention
The nurse is auscultating a client's heart sounds. Which description should the nurse use to
document this sound? (Please listen to the audio first to select the option that applies)
Murmur
A 30 month-old child is admitted to the hospital unit. Which of the following toys would be
appropriate for the nurse to select from the toy room for this child?
A) Cartoon stickers
B) Large wooden puzzle
C) Blunt scissors and paper
D) Beach ball
B) Large wooden puzzle
A nurse is to present information about Chinese folk medicine to a group of student
nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the
A) Yang, the positive force that represents light, warmth, and fullness
B) Yin, the negative force that represents darkness, cold, and emptiness
C) Use of improper hot foods, herbs and plants
D) A failure to keep life in balance with nature and others
B) Yin, the negative force that represents darkness, cold, and emptiness
,A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse
"What is our major concern now, and what will we have to deal with in the future?" Which of the
following is the best response?
A) "There is a probability of life-long complications."
B) "Cystic fibrosis results in nutritional concerns that can be dealt with."
C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
D) "You will work with a team of experts and also have access to a support group that the family
can attend."
C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
Which type of accidental poisoning would the nurse expect to occur in children under
age 6?
A) Oral ingestion
B) Topical contact
C) Inhalation
D) Eye splashes
A) Oral ingestion
A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly
bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and
demands constant attention from the staff. Which activity would be best for the client?
A) Reading
B) Checkers
C) Cards
D) Ping-pong
D) Ping-pong
The nurse is caring for a client who has developed cardiac tamponade. Which finding
would the nurse anticipate?
A) Widening pulse pressure
B) Pleural friction rub
C) Distended neck veins
,D) Bradycardia
C) Distended neck veins
Which nursing action is a priority as the plan of care is developed for a 7 year-old
child hospitalized for acute glomerulonephritis?
A) Assess for generalized edema
B) Monitor for increased urinary output
C) Encourage rest during hyperactive periods
D) Note patterns of increased blood pressure
D) Note patterns of increased blood pressure
The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the
following actions by the nurse would be appropriate?
A) Schedule the therapy thirty minutes after meals
B) Teach the child not to cough during the treatment
C) Confine the percussion to the rib cage area
D) Place the child in a prone position for the therapy
C) Confine the percussion to the rib cage area
Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic
drugs?
A) Orthostatic hypotension is a common side effect
B) Most antipsychotic drugs cause elevated blood pressure
C) This provides information on the amount of sodium allowed in the diet
D) It will indicate the need to institute anti parkinsonian drugs
A) Orthostatic hypotension is a common side effect
.
The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity.
Which choice indicates the client understands dietary needs?
, A) Three apricots
B) Medium banana
C) Naval orange
D) Baked potato
D) Baked potato
.
An 86 year-old nursing home resident who has decreased mental status is hospitalized with
pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid
diet, the client begins to cough. What should the nurse do next?
A) Add a thickening agent to the fluids
B) Check the client's gag reflex
C) Feed the client only solid foods
D) Increase the rate of intravenous fluids
B) Check the client's gag reflex
.
The nurse is planning care for a client with a CVA. Which of the following measures planned by the
nurse would be most effective in preventing skin breakdown?
A) Place client in the wheelchair for four hours each day
B) Pad the bony prominence
C) Reposition every two hours
D) Massage reddened bony prominence
C) Reposition every two hours
.
A nurse is assessing several clients in a long term health care facility. Which client is at highest
risk for development of decubitus ulcers?
A) A 79 year-old malnourished client on bed rest
B) An obese client who uses a wheelchair
C) A client who had 3 incontinent diarrhea stools
D) An 80 year-old ambulatory diabetic client
