HESI Exit Exam Version 1 – 200+ Answered
Questions
While assessing a radial artery catheter, the client complains of numbness and
pain distal to the insertion site. What interventions should the nurse implement?:
Promptly remove the arterial catheter from the radial artery.
An elderly female is admitted because of a change in her level of sensorium.
During the evening shift, the client attempts to get out bed and falls, breaking her
left hip. Buck's skin traction is applied to the left leg while waiting for surgery.
Which intervention is most important for the nurse to include in this client's plan
care?: Ensure proper alignment of the leg in traction.
A client who had a right hip replacement 3 day ago is pale has diminished breath
sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen
saturation rate of 90%. The client is scheduled to be transferred to a skilled
nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the
client's symptoms, what recommendation should the nurse give the healthcare
provider?: Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
prescription for metformin (Glucophage) 500 mg PO twice daily. What information
should the nurse include in this client's teaching plan? (Select all that apply.):
Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
,The nurse is developing an educational program for older clients who are being
discharged with new antihypertensive medications. The nurse should ensure that
the educational materials include which
characteristics? Select all that apply: Written at a twelfth grade reading
level Contains a list with definitions of unfamiliar terms
Uses common words with few Syllables
Printed using a 12 point type font
Uses pictures to help illustrate complex ideas
Rationale: During the aging process older clients often experience sensory
or cognitive changes, such as decreased visual or hearing acuity, slower
thought or reasoning processes, and shorter attention span. Materials for
this age group should include at least of terms, such as a medical
terminology that incline may not know and use common words that
expresses information clearly and simply. Simple, attractive pictures help
hold the learner's attention. The reading level of material should be at the
4th to 5th grade level. Materials should be printed using large font (18-point
or higher), not the standard 12-point font.
During the admission assessment, the nurse auscultates heart sounds for a client
with no history of cardiovascular disease. Where should the nurse listen when
assessing the client's point of maximal
impulse (PMI) (Click the chosen location. To change, click on a new location): Left
Fourth Intercostal Space
An older male adult resident of long-term care facility is hospitalized for a cardiac
catheterization that occurred yesterday. Since the procedure was conducted, the
client has become increasingly disoriented. The night shift nurse reports that he
attempted to remove the sandbag from his femoral artery multiple times during the
night. What actions should the nurse take?
(Select all that apply.): Notify the healthcare provider of the client's change in
mental status.
,Include q2 hour's reorientation in the client's plan of care.
An older male comes to the clinic with a family member. When the nurse attempts
to take the client's health history, he does not respond to questions in a clear
manner. What action should the nurse implement first?: Assess the surroundings
for noise and distractions.
The nurse caring for a client with acute renal fluid (ARF) has noted that the client
has voided 800 ml of urine in 4 hours. Based on this assessment, what should the
nurse anticipate that client will need?: Large amounts of fluid and electrolyte
replacement.
Which intervention should the nurse include in the plan of care for a child
with tetanus?: Minimize the amount of stimuli in the room
Suicide precautions are initiated for a child admitted to the mental health unit
following an intentional narcotic overdose. After a visitor leaves, the nurse finds a
package of cigarettes in the client's room.
Which intervention is most important for the nurse to implement?: Remove
cigarettes for the client's room
A family member of a frail elderly adult asks the nurse about eligibility
requirements for hospice care.
What information should the nurse provide? (Select all that apply.): A client must
be willing to accept palliative care, not curative care.
The healthcare provider must project that the client has 6 months or less to live.
A client with atrial fibrillation receives a new prescription for dabigatran.
, What instruction should the nurse include in this client's teaching plan?: Avoid use
of nonsteroidal ant-inflammatory drugs (NSAID).
A nurse with 10 years experience working in the emergency room is reassigned to
the perinatal unit to work an 8 hour shift. Which client is best to assign to this
nurse?: A mother with an infected episiotomy
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is
irritable and diaphoretic with jugular vein distention. Which prescription should the
nurse administer first?: Digoxin.
The nursing staff on a medical unit includes a registered nurse (RN), practical
nurse (PN), and an unlicensed assistive personnel (UAP). Which task should
the charge nurse assign to the RN?: Supervise a newly hired graduate nurse
during an admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed
asthma, the client stares into the distance and appears to be concentrating on
something other than the lesson the nurse is presenting. What action should the
nurse take?: Ask the client what he is thinking about at his time.
After several hours of non-productive coughing, a client presents to the
emergency room complaining of chest tightness and shortness of breath. History
includes end stage chronic obstructive pulmonary disease (COPD) and diabetes
mellitus. While completing the pulmonary assessment, the nurse hears wheezing
and poor air movement bilaterally. Which actions should the nurse implement?
(Select all that apply.): Administer PRN nebulizer treatment.
Obtain 12 lead electrocardiogram.
Monitor continuous oxygen saturation.
Questions
While assessing a radial artery catheter, the client complains of numbness and
pain distal to the insertion site. What interventions should the nurse implement?:
Promptly remove the arterial catheter from the radial artery.
An elderly female is admitted because of a change in her level of sensorium.
During the evening shift, the client attempts to get out bed and falls, breaking her
left hip. Buck's skin traction is applied to the left leg while waiting for surgery.
Which intervention is most important for the nurse to include in this client's plan
care?: Ensure proper alignment of the leg in traction.
A client who had a right hip replacement 3 day ago is pale has diminished breath
sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen
saturation rate of 90%. The client is scheduled to be transferred to a skilled
nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the
client's symptoms, what recommendation should the nurse give the healthcare
provider?: Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a
prescription for metformin (Glucophage) 500 mg PO twice daily. What information
should the nurse include in this client's teaching plan? (Select all that apply.):
Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
,The nurse is developing an educational program for older clients who are being
discharged with new antihypertensive medications. The nurse should ensure that
the educational materials include which
characteristics? Select all that apply: Written at a twelfth grade reading
level Contains a list with definitions of unfamiliar terms
Uses common words with few Syllables
Printed using a 12 point type font
Uses pictures to help illustrate complex ideas
Rationale: During the aging process older clients often experience sensory
or cognitive changes, such as decreased visual or hearing acuity, slower
thought or reasoning processes, and shorter attention span. Materials for
this age group should include at least of terms, such as a medical
terminology that incline may not know and use common words that
expresses information clearly and simply. Simple, attractive pictures help
hold the learner's attention. The reading level of material should be at the
4th to 5th grade level. Materials should be printed using large font (18-point
or higher), not the standard 12-point font.
During the admission assessment, the nurse auscultates heart sounds for a client
with no history of cardiovascular disease. Where should the nurse listen when
assessing the client's point of maximal
impulse (PMI) (Click the chosen location. To change, click on a new location): Left
Fourth Intercostal Space
An older male adult resident of long-term care facility is hospitalized for a cardiac
catheterization that occurred yesterday. Since the procedure was conducted, the
client has become increasingly disoriented. The night shift nurse reports that he
attempted to remove the sandbag from his femoral artery multiple times during the
night. What actions should the nurse take?
(Select all that apply.): Notify the healthcare provider of the client's change in
mental status.
,Include q2 hour's reorientation in the client's plan of care.
An older male comes to the clinic with a family member. When the nurse attempts
to take the client's health history, he does not respond to questions in a clear
manner. What action should the nurse implement first?: Assess the surroundings
for noise and distractions.
The nurse caring for a client with acute renal fluid (ARF) has noted that the client
has voided 800 ml of urine in 4 hours. Based on this assessment, what should the
nurse anticipate that client will need?: Large amounts of fluid and electrolyte
replacement.
Which intervention should the nurse include in the plan of care for a child
with tetanus?: Minimize the amount of stimuli in the room
Suicide precautions are initiated for a child admitted to the mental health unit
following an intentional narcotic overdose. After a visitor leaves, the nurse finds a
package of cigarettes in the client's room.
Which intervention is most important for the nurse to implement?: Remove
cigarettes for the client's room
A family member of a frail elderly adult asks the nurse about eligibility
requirements for hospice care.
What information should the nurse provide? (Select all that apply.): A client must
be willing to accept palliative care, not curative care.
The healthcare provider must project that the client has 6 months or less to live.
A client with atrial fibrillation receives a new prescription for dabigatran.
, What instruction should the nurse include in this client's teaching plan?: Avoid use
of nonsteroidal ant-inflammatory drugs (NSAID).
A nurse with 10 years experience working in the emergency room is reassigned to
the perinatal unit to work an 8 hour shift. Which client is best to assign to this
nurse?: A mother with an infected episiotomy
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is
irritable and diaphoretic with jugular vein distention. Which prescription should the
nurse administer first?: Digoxin.
The nursing staff on a medical unit includes a registered nurse (RN), practical
nurse (PN), and an unlicensed assistive personnel (UAP). Which task should
the charge nurse assign to the RN?: Supervise a newly hired graduate nurse
during an admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed
asthma, the client stares into the distance and appears to be concentrating on
something other than the lesson the nurse is presenting. What action should the
nurse take?: Ask the client what he is thinking about at his time.
After several hours of non-productive coughing, a client presents to the
emergency room complaining of chest tightness and shortness of breath. History
includes end stage chronic obstructive pulmonary disease (COPD) and diabetes
mellitus. While completing the pulmonary assessment, the nurse hears wheezing
and poor air movement bilaterally. Which actions should the nurse implement?
(Select all that apply.): Administer PRN nebulizer treatment.
Obtain 12 lead electrocardiogram.
Monitor continuous oxygen saturation.
