HESI RN EXIT EXAM V1
1.The nurse is completing the admission assessment of a 3-year old who is admitted
with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that
the child is experiencing increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope
- CORRECT ANS -B. Sluggish and unequal pupillary responses
2.A patient with acute pancreatitis is admitted with severe, piercing abdominal pain and
an elevated serum amylase. Which additional information is the patient most likely to
report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly.
- CORRECT ANS -A. Abdominal pain decreases when lying supine
3.A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the
hospital. Which information is most important for the nurse to provide the parents prior
to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family
- CORRECT ANS -A. Instructions about how much fluid the child should drink daily
4.After receiving report on an inpatient acute care unit, which patient should the nurse
assess first?
A. The patient with an obstruction of the large intestine who is experiencing abdominal
distention
B. The patient who had surgery yesterday and is experiencing a paralytic ileus with
absent bowel sounds
C. The patient with a small bowel obstruction who has a nasogastric tube that is
draining greenish fluid
D. The patient with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
- CORRECT ANS -D. The patient with a bowel obstruction due to a volvulus who is
experiencing abdominal rigidity
1
,5.A teenager presents to the emergency department with palpitations after vaping at a
party. The patient is anxious, fearful, and hyperventilating. The nurse anticipates the
patient developing which acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
- CORRECT ANS -D. Respiratory alkalosis
6.A patient with dyspnea is being admitted to the medical unit. To best prepare for the
patient's arrival, the nurse should ensure that the patient's bed is in which position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers
- CORRECT ANS -Fowlers
7.The nurse is taking the blood pressure measurement of a patient with Parkinson's
disease. Which information in the patient's admission assessment is relevant to the
nurse's plan for taking the blood pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling
CORRECT ANS -A. Frequent syncope
8.While caring for a patient's postoperative dressing, the nurse observes purulent
drainage at the wound. Before reporting this finding to the healthcare provider, the
nurse should review which of the patient's laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level
- CORRECT ANS -B. Culture for sensitive organisms
9.A preschool-aged boy is admitted to the pediatric unit following successful
resuscitation from a near-drowning incident. While providing care to the child, the nurse
begins talking with his preadolescent brother who rescued the child from the swimming
pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn
when asked about what happened. Which action should the nurse take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
2
,D. Commend the older brother for his heroic actions
- CORRECT ANS -B. Ask the older brother how he felt during the incident
10.A male patient with cirrhosis has jaundice and pruritus. He tells the nurse that he has
been soaking in hot baths at night with no relief of his discomfort. Which action should
the nurse take?
A. Encourage the patient to use cooler water and apply calamine lotion after soaking
B. Obtain a PRN prescription for an analgesic that the patient can use for symptom
relief
C. Suggest that the patient take brief showers and apply oil-based lotion after showering
D. Explain that the symptoms are caused by liver damage and cannot be relieved
- CORRECT ANS -A. Encourage the patient to use cooler water and apply calamine
lotion after soaking
11.An older patient with a long history of coronary artery disease (CAD), hypertension
(HTN), and heart failure (HF) arrives in the Emergency Department (ED) in respiratory
distress. The healthcare provider prescribes furosemide IV. Which therapeutic response
to furosemide should the nurse expected in the patient with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload
- CORRECT ANS -B. Reduced preload
12.Which intervention should the nurse include in the plan of care for a child with
tetanus?
A. Encourage coughing and deep breathing
B. Minimize the amount of stimuli in the room
C. Reposition from side to side every hour
D. Open window shades to provide natural light
- CORRECT ANS -B. Minimize the amount of stimuli in the room
13.An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is
admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely
cause of the ketoacidosis?
A. Ate an extra peanut butter sandwich before gym class
B. incorrectly administered too much insulin
C. Had a cold and ear infection for the past two days
D. Skipped eating lunch
- CORRECT ANS -C. Had a cold and ear infection for the past two days
14.A patient with a prescription for "do not resuscitate" (DNR) begins to manifest signs
of impending death. After notifying the family of the patient's status, what priority action
should the nurse implement?
A. The impending signs of death should be documented
B. The patient's status should be conveyed to the chaplain
3
, C. The patient's need for pain medication should be determined
D. The nurse manager should be updated on the patient's status
- CORRECT ANS -C. The patient's need for pain medication should be determined
15.Which self care measure is most important for the nurse to include in the plan of care
of a patient recently diagnosed with type 2 diabetes mellitus?
A. Self-injection techniques
B. Blood glucose monitoring
C. Diabetic diet meal planning
D. A realistic exercise plan
- CORRECT ANS -B. Blood glucose monitoring
16.A patient who gave birth 48 hours ago has decided to bottle feed the infant. During
the assessment, the nurse observes that both breasts are swollen, warm, and tender on
palpation. Which instruction should the nurse provide?
A. Apply ice to the breasts for comfort
B. Wear a loose-fitting bra during the day to prevent nipple irritation
C. Run warm water over breasts
D. Express small amounts of milk from the breasts to relieve pressure
- CORRECT ANS -A. Apply ice to the breasts for comfort
17.The nurse is preparing a patient who had a below-the-knee (BKA) amputation for
discharge to home. Which recommendations should the nurse provide this patient?
(Select all that apply)
A. Avoid range of motion exercises
B. Use a residual limb shrinker
C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
E. Wash the stump with soap and water
- CORRECT ANS -B. Use a residual limb shrinke
18.A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain,
and vomiting that occurs after ingesting of milk products arrives to the clinic
accompanied by the parents. Which type of testing should the nurse provide education
to the toddler's family about?
A. Serum immunoglobulin E (IgE)
B. Intradermal test
C. Atopy patch test
D. Placebo-controlled food challenge
- CORRECT ANS -A. Serum immunoglobulin E (IgE)
19.A patient who is scheduled for a bronchoscopy in the morning is anxious and asking
the nurse numerous questions about the procedure. In preparing the patient for the
procedure, which intervention has the highest priority?
A. Allow patient to gargle with warm salt water
B. Administer a sedative to alleviate anxiety
4
1.The nurse is completing the admission assessment of a 3-year old who is admitted
with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that
the child is experiencing increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope
- CORRECT ANS -B. Sluggish and unequal pupillary responses
2.A patient with acute pancreatitis is admitted with severe, piercing abdominal pain and
an elevated serum amylase. Which additional information is the patient most likely to
report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly.
- CORRECT ANS -A. Abdominal pain decreases when lying supine
3.A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the
hospital. Which information is most important for the nurse to provide the parents prior
to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family
- CORRECT ANS -A. Instructions about how much fluid the child should drink daily
4.After receiving report on an inpatient acute care unit, which patient should the nurse
assess first?
A. The patient with an obstruction of the large intestine who is experiencing abdominal
distention
B. The patient who had surgery yesterday and is experiencing a paralytic ileus with
absent bowel sounds
C. The patient with a small bowel obstruction who has a nasogastric tube that is
draining greenish fluid
D. The patient with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
- CORRECT ANS -D. The patient with a bowel obstruction due to a volvulus who is
experiencing abdominal rigidity
1
,5.A teenager presents to the emergency department with palpitations after vaping at a
party. The patient is anxious, fearful, and hyperventilating. The nurse anticipates the
patient developing which acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
- CORRECT ANS -D. Respiratory alkalosis
6.A patient with dyspnea is being admitted to the medical unit. To best prepare for the
patient's arrival, the nurse should ensure that the patient's bed is in which position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers
- CORRECT ANS -Fowlers
7.The nurse is taking the blood pressure measurement of a patient with Parkinson's
disease. Which information in the patient's admission assessment is relevant to the
nurse's plan for taking the blood pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling
CORRECT ANS -A. Frequent syncope
8.While caring for a patient's postoperative dressing, the nurse observes purulent
drainage at the wound. Before reporting this finding to the healthcare provider, the
nurse should review which of the patient's laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level
- CORRECT ANS -B. Culture for sensitive organisms
9.A preschool-aged boy is admitted to the pediatric unit following successful
resuscitation from a near-drowning incident. While providing care to the child, the nurse
begins talking with his preadolescent brother who rescued the child from the swimming
pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn
when asked about what happened. Which action should the nurse take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
2
,D. Commend the older brother for his heroic actions
- CORRECT ANS -B. Ask the older brother how he felt during the incident
10.A male patient with cirrhosis has jaundice and pruritus. He tells the nurse that he has
been soaking in hot baths at night with no relief of his discomfort. Which action should
the nurse take?
A. Encourage the patient to use cooler water and apply calamine lotion after soaking
B. Obtain a PRN prescription for an analgesic that the patient can use for symptom
relief
C. Suggest that the patient take brief showers and apply oil-based lotion after showering
D. Explain that the symptoms are caused by liver damage and cannot be relieved
- CORRECT ANS -A. Encourage the patient to use cooler water and apply calamine
lotion after soaking
11.An older patient with a long history of coronary artery disease (CAD), hypertension
(HTN), and heart failure (HF) arrives in the Emergency Department (ED) in respiratory
distress. The healthcare provider prescribes furosemide IV. Which therapeutic response
to furosemide should the nurse expected in the patient with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload
- CORRECT ANS -B. Reduced preload
12.Which intervention should the nurse include in the plan of care for a child with
tetanus?
A. Encourage coughing and deep breathing
B. Minimize the amount of stimuli in the room
C. Reposition from side to side every hour
D. Open window shades to provide natural light
- CORRECT ANS -B. Minimize the amount of stimuli in the room
13.An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is
admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely
cause of the ketoacidosis?
A. Ate an extra peanut butter sandwich before gym class
B. incorrectly administered too much insulin
C. Had a cold and ear infection for the past two days
D. Skipped eating lunch
- CORRECT ANS -C. Had a cold and ear infection for the past two days
14.A patient with a prescription for "do not resuscitate" (DNR) begins to manifest signs
of impending death. After notifying the family of the patient's status, what priority action
should the nurse implement?
A. The impending signs of death should be documented
B. The patient's status should be conveyed to the chaplain
3
, C. The patient's need for pain medication should be determined
D. The nurse manager should be updated on the patient's status
- CORRECT ANS -C. The patient's need for pain medication should be determined
15.Which self care measure is most important for the nurse to include in the plan of care
of a patient recently diagnosed with type 2 diabetes mellitus?
A. Self-injection techniques
B. Blood glucose monitoring
C. Diabetic diet meal planning
D. A realistic exercise plan
- CORRECT ANS -B. Blood glucose monitoring
16.A patient who gave birth 48 hours ago has decided to bottle feed the infant. During
the assessment, the nurse observes that both breasts are swollen, warm, and tender on
palpation. Which instruction should the nurse provide?
A. Apply ice to the breasts for comfort
B. Wear a loose-fitting bra during the day to prevent nipple irritation
C. Run warm water over breasts
D. Express small amounts of milk from the breasts to relieve pressure
- CORRECT ANS -A. Apply ice to the breasts for comfort
17.The nurse is preparing a patient who had a below-the-knee (BKA) amputation for
discharge to home. Which recommendations should the nurse provide this patient?
(Select all that apply)
A. Avoid range of motion exercises
B. Use a residual limb shrinker
C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
E. Wash the stump with soap and water
- CORRECT ANS -B. Use a residual limb shrinke
18.A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain,
and vomiting that occurs after ingesting of milk products arrives to the clinic
accompanied by the parents. Which type of testing should the nurse provide education
to the toddler's family about?
A. Serum immunoglobulin E (IgE)
B. Intradermal test
C. Atopy patch test
D. Placebo-controlled food challenge
- CORRECT ANS -A. Serum immunoglobulin E (IgE)
19.A patient who is scheduled for a bronchoscopy in the morning is anxious and asking
the nurse numerous questions about the procedure. In preparing the patient for the
procedure, which intervention has the highest priority?
A. Allow patient to gargle with warm salt water
B. Administer a sedative to alleviate anxiety
4
