RN readiness exam(hesi)
The nurse is monitoring neurological vital signs for a male client who lost consciousness
after falling and hitting his head. Which assessment finding is the earliest and most
sensitive indication of altered cerebral function?
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness. - ANS>>D
A nurse is planning to teach self-care measures to a female client about prevention of
yeast infections. Which instructions should the nurse provide?
a. Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and comfortable.
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts. - ANS>>D
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is
most important for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room. - ANS>>D
The nurse is planning to conduct nutritional assessments and diet teaching to clients at
a family health clinic. Which individual has the greatest nutritional and energy
demands?
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child. - ANS>>A
What nursing delivery of care provides the nurse to plan and direct care of a group of
clients over a 24-hour period?
a. Team nursing.
b. Primary nursing.
c. Case management.
d. Functional nursing. - ANS>>B
Which approach should the nurse use when preparing a toddler for a procedure?
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
c. Plan a teaching session to last about 20 minutes.
,d. Show equipment but prevent child from handling it. - ANS>>A
The nurse is caring for a client who is the daughter of a local politician. When the nurse
approaches a man who is reading the names on the hall doors, he identifies himself as
a reporter for the local newspaper and requests information about the client's status.
Which standard of nursing practice should the nurse use to respond?
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality. - ANS>>D
A male client diagnosed with antisocial personality disorder is morbidly obese and is
placed on a low fat, low calorie diet. At dinner the nurse notes that he is trying to get
other clients on the unit to give him part of their meals. What intervention should the
nurse implement?
a. Remove the client from the table and have him sit alone.
b. Send the client back to his room and do not allow him to eat.
c. Report the behavior to the on-call psychologist immediately.
d. Confront the client about the consequences of the behavior. - ANS>>D
Which information should the nurse give a client with chronic kidney disease (CKD)?
a. Restrict calcium-rich foods.
b. Obtain monthly B12 injections.
c. Avoid salt substitutes.
d. Increase daily intake of fiber. - ANS>>C
The nurse is assessing a client who complains of weight loss, racing heart rate, and
difficulty sleeping. The nurse determines the client has moist skin with fine hair,
prominent eyes, lid retraction, and a staring expression. These findings are consistent
with which disorder?
a. Grave's disease.
b. Cushing syndrome.
c. Multiple sclerosis.
d. Addison's disease. - ANS>>A
A young adult female arrives at the emergency department with a black right eye and is
bleeding from the left side of her head. She reports that her boyfriend has been abusing
her physically. The nurse performs a history and physical examination. How should the
nurse document these findings?
a. Client alleges that her boyfriend beat her up. Client is bleeding from the left side of
the face.
b. Client reports her boyfriend hit her in the eye and on the head. Bruises and
lacerations present on face.
, c. Client presents with a right black eye and a cut on the left side of her head that is
bleeding. Reports abusive boyfriend responsible for injuries. Needs referral to a safe
place to stay.
d. Young adult female presents with periorbital ecchymosis on right side, 3 cm
laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her
boyfriend is abusive. - ANS>>D
A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of
major depression. The initial nursing care plan includes the goal, "Assist client to
express feelings of anger." Which nursing intervention is most important to include in
the client's plan of care?
a. Teach that anger will subside after two weeks on antidepressants.
b. Ask client to describe triggers of anger.
c. Gather more data about social support.
d. Collaborate with the treatment team about revising the goal. - ANS>>B
The nurse determines that a client's body weight is 105% above the standardized
height-weight scale. Which related factor should the nurse include in the nursing
problem, "Imbalanced nutrition: more than body requirements?"
a. Morbidly obese.
b. Markedly obese.
c. Inadequate lifestyle changes in diet and exercise.
d. Increased morbidity and mortality risks. - ANS>>C
A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 ml for the
first 10 kg of body weight, plus 50 ml/kg per day for each kilogram between 10 and 20.
How many milliliters per hour should the nurse program the infusion pump for a child
who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the
nearest whole number.) - ANS>>61
A 6-year-old child is alert but quiet when brought to the emergency center with
periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential
child abuse and continues to assess the child for additional manifestations of a basilar
skull fracture. What assessment finding would be consistent with a basilar skull
fracture?
a. Asymmetry of the face and eye movements.
b. Abnormal position and movement of the arm.
c. Hematemesis and abdominal distention.
d. Rhinorrhoea or otorrhoea with Halo sign - ANS>>D
The nurse is assessing a client and identifies the presence of petechiae. Which
documentation best describes this finding?
a. Purplish-red pinpoint lesions of the skin.
b. Purple to bluish discoloration of the skin.
c. Small circumscribed elevations containing purulent fluid.
d. Generalized reddish discoloration of an area of skin. - ANS>>A
The nurse is monitoring neurological vital signs for a male client who lost consciousness
after falling and hitting his head. Which assessment finding is the earliest and most
sensitive indication of altered cerebral function?
a. Unequal pupils.
b. Loss of central reflexes.
c. Inability to open the eyes.
d. Change in level of consciousness. - ANS>>D
A nurse is planning to teach self-care measures to a female client about prevention of
yeast infections. Which instructions should the nurse provide?
a. Use a douche preparation no more than once a month.
b. Increase daily intake of fiber and leafy green vegetables.
c. Select nylon underwear that is loose-fitting, white, and comfortable.
d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts. - ANS>>D
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is
most important for the nurse to implement?
a. Place an isolation cart in the hallway.
b. Fit the client with a respirator mask.
c. Don a clean gown for client care.
d. Assign the client to a negative air-flow room. - ANS>>D
The nurse is planning to conduct nutritional assessments and diet teaching to clients at
a family health clinic. Which individual has the greatest nutritional and energy
demands?
a. A pregnant woman.
b. A teenager beginning puberty.
c. A 3-month-old infant.
d. A school-aged child. - ANS>>A
What nursing delivery of care provides the nurse to plan and direct care of a group of
clients over a 24-hour period?
a. Team nursing.
b. Primary nursing.
c. Case management.
d. Functional nursing. - ANS>>B
Which approach should the nurse use when preparing a toddler for a procedure?
a. Demonstrate the procedure using a doll.
b. Avoid asking the child to make choices.
c. Plan a teaching session to last about 20 minutes.
,d. Show equipment but prevent child from handling it. - ANS>>A
The nurse is caring for a client who is the daughter of a local politician. When the nurse
approaches a man who is reading the names on the hall doors, he identifies himself as
a reporter for the local newspaper and requests information about the client's status.
Which standard of nursing practice should the nurse use to respond?
a. Caring.
b. Veracity.
c. Advocacy.
d. Confidentiality. - ANS>>D
A male client diagnosed with antisocial personality disorder is morbidly obese and is
placed on a low fat, low calorie diet. At dinner the nurse notes that he is trying to get
other clients on the unit to give him part of their meals. What intervention should the
nurse implement?
a. Remove the client from the table and have him sit alone.
b. Send the client back to his room and do not allow him to eat.
c. Report the behavior to the on-call psychologist immediately.
d. Confront the client about the consequences of the behavior. - ANS>>D
Which information should the nurse give a client with chronic kidney disease (CKD)?
a. Restrict calcium-rich foods.
b. Obtain monthly B12 injections.
c. Avoid salt substitutes.
d. Increase daily intake of fiber. - ANS>>C
The nurse is assessing a client who complains of weight loss, racing heart rate, and
difficulty sleeping. The nurse determines the client has moist skin with fine hair,
prominent eyes, lid retraction, and a staring expression. These findings are consistent
with which disorder?
a. Grave's disease.
b. Cushing syndrome.
c. Multiple sclerosis.
d. Addison's disease. - ANS>>A
A young adult female arrives at the emergency department with a black right eye and is
bleeding from the left side of her head. She reports that her boyfriend has been abusing
her physically. The nurse performs a history and physical examination. How should the
nurse document these findings?
a. Client alleges that her boyfriend beat her up. Client is bleeding from the left side of
the face.
b. Client reports her boyfriend hit her in the eye and on the head. Bruises and
lacerations present on face.
, c. Client presents with a right black eye and a cut on the left side of her head that is
bleeding. Reports abusive boyfriend responsible for injuries. Needs referral to a safe
place to stay.
d. Young adult female presents with periorbital ecchymosis on right side, 3 cm
laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her
boyfriend is abusive. - ANS>>D
A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of
major depression. The initial nursing care plan includes the goal, "Assist client to
express feelings of anger." Which nursing intervention is most important to include in
the client's plan of care?
a. Teach that anger will subside after two weeks on antidepressants.
b. Ask client to describe triggers of anger.
c. Gather more data about social support.
d. Collaborate with the treatment team about revising the goal. - ANS>>B
The nurse determines that a client's body weight is 105% above the standardized
height-weight scale. Which related factor should the nurse include in the nursing
problem, "Imbalanced nutrition: more than body requirements?"
a. Morbidly obese.
b. Markedly obese.
c. Inadequate lifestyle changes in diet and exercise.
d. Increased morbidity and mortality risks. - ANS>>C
A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 ml for the
first 10 kg of body weight, plus 50 ml/kg per day for each kilogram between 10 and 20.
How many milliliters per hour should the nurse program the infusion pump for a child
who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the
nearest whole number.) - ANS>>61
A 6-year-old child is alert but quiet when brought to the emergency center with
periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential
child abuse and continues to assess the child for additional manifestations of a basilar
skull fracture. What assessment finding would be consistent with a basilar skull
fracture?
a. Asymmetry of the face and eye movements.
b. Abnormal position and movement of the arm.
c. Hematemesis and abdominal distention.
d. Rhinorrhoea or otorrhoea with Halo sign - ANS>>D
The nurse is assessing a client and identifies the presence of petechiae. Which
documentation best describes this finding?
a. Purplish-red pinpoint lesions of the skin.
b. Purple to bluish discoloration of the skin.
c. Small circumscribed elevations containing purulent fluid.
d. Generalized reddish discoloration of an area of skin. - ANS>>A
