HESI Exit RN V4 newest exam 2024
A client has just been admitted with portal hypertension. Which nursing diagnosis
would be a priority in planning care?
A) Altered nutrition: less than body requirements
B) Potential complication hemorrhage
C) Ineffective individual coping
D) Fluid volume excess - Answer-B: Potential complication hemorrhage
While planning care for a 2 year-old hospitalized child, which situation would the
nurse expect to most likely affect the behavior?
A) Strange bed and surroundings
B) Separation from parents
C) Presence of other toddlers
D) Unfamiliar toys and games - Answer-B: Separation from parents
Which of the following should the nurse teach the client to avoid when taking
chlorpromazine HCL (Thorazine)?
Direct sunlight
Foods containing tyramine
Foods fermented with yeast
Canned citrus fruit drinks - Answer-A: Avoid direct sunlight
The initial response by the nurse to a delusional client who refuses to eat because
,of a belief that the food is poisoned is
"You think that someone wants to poison you?"
"Why do you think the food is poisoned?"
"These feelings are a symptom of your illness."
"You're safe here. I won't let anyone poison you." - Answer-A: "You think that someone wants
to poison you?"
The nurse is caring for a client with cirrhosis of the liver with ascites. When
instructing nursing assistants in the care of the client, the nurse should emphasize that
The client should remain on bed rest in a semi-Fowler's position
The client should alternate ambulation with bed rest with legs elevated
The client may ambulate and sit in chair as tolerated
The client may ambulate as tolerated and remain in semi-Fowler position in bed - Answer-B:
The client should alternate ambulation with bed rest with legs elevated
The nurse is performing physical assessments on adolescents. When would the
nurse anticipate that females experience growth spurts?
A) About 2 years earlier than males B) About the same time as males
Just prior to the onset of puberty
That increase height by 4 inches each year - Answer-A: About 2 years earlier than males
The nurse is assessing the mental status of a client admitted with possible organic brain
disorder. Which of these questions will best assess the function of the client's recent
memory?
A) "Name the year." "What season is this?" (pause for answer after each question)
"Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to
subtract 7 from the new number."
,"I am going to say the names of three things and I want you to repeat them after me: blue,
ball, pen."
"What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?" -
Answer-C: "I am going to say the names of three things and I want you to repeat them after
me: blue, ball, pen."
In planning care for a 6 month-old infant, what must the nurse provide to assist in the
development of trust?
A) Food
B) Warmth
C) Security
D) Comfort - Answer-C: Security
A nurse has just received a medication order which is not legible. Which statement
best reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean." B) "Would
you please clarify what you have written so I am sure I am reading it correctly?"
"I am having difficulty reading your handwriting. It would save me time if you would be more
careful."
"Please print in the future so I do not have to spend extra time attempting to read your
writing." - Answer-B) "Would you please clarify what you have written so I am sure I am
reading it correctly?"
What is the most important consideration when teaching parents how to reduce risks
in the home?
Age and knowledge level of the parents
Proximity to emergency services
Number of children in the home
, Age of children in the home - Answer-D: Age of children in the home
A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the
nurse enters the room to request something for pain. The nurse should
Administer a placebo
Encourage increased fluid intake
Administer the prescribed analgesia
Recommend relaxation exercises for pain control - Answer-C: Administer the prescribed
analgesia
10. While caring for a toddler with croup, which initial sign of croup requires the nurse's
immediate attention?
A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions - Answer-A: Respiratory rate of 30
A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment,
the nurse would anticipate which of the following assessment findings?
A) Lethargy
B) Heat intolerance
C) Diarrhea
D) Skin eruptions - Answer-A: Lethargy
The emergency room nurse admits a child who experienced a seizure at school. The father
comments that this is the first occurrence, and denies any family history of epilepsy. What is
the best response by the nurse?
A client has just been admitted with portal hypertension. Which nursing diagnosis
would be a priority in planning care?
A) Altered nutrition: less than body requirements
B) Potential complication hemorrhage
C) Ineffective individual coping
D) Fluid volume excess - Answer-B: Potential complication hemorrhage
While planning care for a 2 year-old hospitalized child, which situation would the
nurse expect to most likely affect the behavior?
A) Strange bed and surroundings
B) Separation from parents
C) Presence of other toddlers
D) Unfamiliar toys and games - Answer-B: Separation from parents
Which of the following should the nurse teach the client to avoid when taking
chlorpromazine HCL (Thorazine)?
Direct sunlight
Foods containing tyramine
Foods fermented with yeast
Canned citrus fruit drinks - Answer-A: Avoid direct sunlight
The initial response by the nurse to a delusional client who refuses to eat because
,of a belief that the food is poisoned is
"You think that someone wants to poison you?"
"Why do you think the food is poisoned?"
"These feelings are a symptom of your illness."
"You're safe here. I won't let anyone poison you." - Answer-A: "You think that someone wants
to poison you?"
The nurse is caring for a client with cirrhosis of the liver with ascites. When
instructing nursing assistants in the care of the client, the nurse should emphasize that
The client should remain on bed rest in a semi-Fowler's position
The client should alternate ambulation with bed rest with legs elevated
The client may ambulate and sit in chair as tolerated
The client may ambulate as tolerated and remain in semi-Fowler position in bed - Answer-B:
The client should alternate ambulation with bed rest with legs elevated
The nurse is performing physical assessments on adolescents. When would the
nurse anticipate that females experience growth spurts?
A) About 2 years earlier than males B) About the same time as males
Just prior to the onset of puberty
That increase height by 4 inches each year - Answer-A: About 2 years earlier than males
The nurse is assessing the mental status of a client admitted with possible organic brain
disorder. Which of these questions will best assess the function of the client's recent
memory?
A) "Name the year." "What season is this?" (pause for answer after each question)
"Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to
subtract 7 from the new number."
,"I am going to say the names of three things and I want you to repeat them after me: blue,
ball, pen."
"What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?" -
Answer-C: "I am going to say the names of three things and I want you to repeat them after
me: blue, ball, pen."
In planning care for a 6 month-old infant, what must the nurse provide to assist in the
development of trust?
A) Food
B) Warmth
C) Security
D) Comfort - Answer-C: Security
A nurse has just received a medication order which is not legible. Which statement
best reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean." B) "Would
you please clarify what you have written so I am sure I am reading it correctly?"
"I am having difficulty reading your handwriting. It would save me time if you would be more
careful."
"Please print in the future so I do not have to spend extra time attempting to read your
writing." - Answer-B) "Would you please clarify what you have written so I am sure I am
reading it correctly?"
What is the most important consideration when teaching parents how to reduce risks
in the home?
Age and knowledge level of the parents
Proximity to emergency services
Number of children in the home
, Age of children in the home - Answer-D: Age of children in the home
A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the
nurse enters the room to request something for pain. The nurse should
Administer a placebo
Encourage increased fluid intake
Administer the prescribed analgesia
Recommend relaxation exercises for pain control - Answer-C: Administer the prescribed
analgesia
10. While caring for a toddler with croup, which initial sign of croup requires the nurse's
immediate attention?
A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions - Answer-A: Respiratory rate of 30
A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment,
the nurse would anticipate which of the following assessment findings?
A) Lethargy
B) Heat intolerance
C) Diarrhea
D) Skin eruptions - Answer-A: Lethargy
The emergency room nurse admits a child who experienced a seizure at school. The father
comments that this is the first occurrence, and denies any family history of epilepsy. What is
the best response by the nurse?
