Hesi Exit Review
The mother of a child with cerebral palsy asks the nurse if her child's impaired movements will worsen
as the child grows which response provides the best explanation? *** Brain damage with CP is not
progressive but does have a variable course.
During shift report the central electrocardiogram monitoring system alarms which client alarm should
the nurse investigate first? *** Respiratory apnea of 30 seconds
The nurse is assessing A postpartum client who is 36 hours post-delivery which finding should the nurse
report to the health care provider? *** Oral temperature of 100.6 Fahrenheit
An older woman who has difficulty hearing is being discharged from day surgery following a cataract
extraction and lens implantation which intervention is most important for the nurse to implement to
help ensure the client's compliance with self-care? *** Have client vocalize the instructions provided
A client with diabetic peripheral nephropathy has been taking pregabalin Lyrica for four days which
finding indicates to the nurse that the medication is effective? *** Reduce pain level
A client presents to the emergency department with muscle aches headache fever and describes a
recent loss of taste and smell the nurse obtains A nasal swab for COVID-19 testing which action is most
important for the nurse to take? *** Place the nasal swab specimen for COVID-19 directly into a
biohazard bag.
A client who experienced a cerebrovascular accident CVA is aphasic and has left-sided paralysis which
nurse should be responsible for coordinating the progression of this client's care? *** adult nurse
practitioner
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day
refuses to take a bath and refuses to eat which nursing intervention should the nurse implement first?
*** Establish a structured routine for the client to follow.
,A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor which
finding should the nurse report to the health care provider before initiating the infusion of oxytocin? ***
Fetal heart tones located in upper right quadrant
A client with type one diabetes mellitus and a large draining ulcer of the right foot is admitted with a
suspected Staphylococcus Aureus infection which intervention should the nurse implement? select all
that apply *** Monitor the clients white blood cell count
send wound drainage for a culture and sensitivity
institute contact precautions for staff and visitors
An adult client is admitted to the psychiatric unit because of daily complex hand washing ritual that
takes 2 hours or longer to complete the client worries about staying clean and refuses to sit on any of
the chairs in the day area the client's hand washing is an example of which clinical behavior? ***
Compulsion
The nurse observes a client prepare a meal in the kitchen of the rehabilitation facility prior to discharge
which behaviors indicates the client understands how to maintain balance safely? Select all that apply
*** Brings a heavy can close to body before lifting.
-Widens stance while working near the sink.
The nurse is interviewing a client with schizophrenia which clinical behaviors requires immediate
intervention? *** Muscle spasms of the back and neck
The nurse assesses a child in 90 to 90 skeletal tractions where should the nurse assess for signs of
compartment syndrome? *** Click spot right on toes on injured foot
, A male client receives a Thrombolytic medication following a Myocardial infarction when the client has a
bowel movement what action should the nurse implement? *** Send stool sample to the lab for a
guaiac test
A client is receiving mesalamine 800mg po TID Which assessment is most important for the nurse to
perform to assess the effectiveness of the medication? *** Bowel patterns
The nurse is assessing a client who reports falling two days ago and has a history of gouty arthritis that is
controlled with allopurinol the client states the left knee is swollen and extremely painful to touch which
instruction should the nurse include in the discharge teaching? *** Decrease consumption of red meat
and seafood
Before leaving the room of the confused client the nurse notes that a half bow knot was used to attach
the clients wrist restraints to the movable portion of the client's bed frame what action should the nurse
take before leaving the room? *** Ensured that the knot can quickly be released.
When caring for a client with a traumatic brain injury who had a craniotomy for increased and cranial
pressure the nurse assesses the client's using the glaucoma scale every two hours for the past eight
hours the client's black oak coma scale score has been 14 what does the glaucoma scale finding
indicates about the client? *** Neurologically stable without in dictation of an increased cranial
pressure
The nurse is managing the care of a client With cushings syndrome which intervention should the nurse
delegate to the unlicensed assistance personnel? SATA *** Report any client complaints of pain or
discomfort
weigh the client and report any weight gain
note and report that clients food and liquid intake during meals and snacks
The mother of a child with cerebral palsy asks the nurse if her child's impaired movements will worsen
as the child grows which response provides the best explanation? *** Brain damage with CP is not
progressive but does have a variable course.
During shift report the central electrocardiogram monitoring system alarms which client alarm should
the nurse investigate first? *** Respiratory apnea of 30 seconds
The nurse is assessing A postpartum client who is 36 hours post-delivery which finding should the nurse
report to the health care provider? *** Oral temperature of 100.6 Fahrenheit
An older woman who has difficulty hearing is being discharged from day surgery following a cataract
extraction and lens implantation which intervention is most important for the nurse to implement to
help ensure the client's compliance with self-care? *** Have client vocalize the instructions provided
A client with diabetic peripheral nephropathy has been taking pregabalin Lyrica for four days which
finding indicates to the nurse that the medication is effective? *** Reduce pain level
A client presents to the emergency department with muscle aches headache fever and describes a
recent loss of taste and smell the nurse obtains A nasal swab for COVID-19 testing which action is most
important for the nurse to take? *** Place the nasal swab specimen for COVID-19 directly into a
biohazard bag.
A client who experienced a cerebrovascular accident CVA is aphasic and has left-sided paralysis which
nurse should be responsible for coordinating the progression of this client's care? *** adult nurse
practitioner
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day
refuses to take a bath and refuses to eat which nursing intervention should the nurse implement first?
*** Establish a structured routine for the client to follow.
,A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor which
finding should the nurse report to the health care provider before initiating the infusion of oxytocin? ***
Fetal heart tones located in upper right quadrant
A client with type one diabetes mellitus and a large draining ulcer of the right foot is admitted with a
suspected Staphylococcus Aureus infection which intervention should the nurse implement? select all
that apply *** Monitor the clients white blood cell count
send wound drainage for a culture and sensitivity
institute contact precautions for staff and visitors
An adult client is admitted to the psychiatric unit because of daily complex hand washing ritual that
takes 2 hours or longer to complete the client worries about staying clean and refuses to sit on any of
the chairs in the day area the client's hand washing is an example of which clinical behavior? ***
Compulsion
The nurse observes a client prepare a meal in the kitchen of the rehabilitation facility prior to discharge
which behaviors indicates the client understands how to maintain balance safely? Select all that apply
*** Brings a heavy can close to body before lifting.
-Widens stance while working near the sink.
The nurse is interviewing a client with schizophrenia which clinical behaviors requires immediate
intervention? *** Muscle spasms of the back and neck
The nurse assesses a child in 90 to 90 skeletal tractions where should the nurse assess for signs of
compartment syndrome? *** Click spot right on toes on injured foot
, A male client receives a Thrombolytic medication following a Myocardial infarction when the client has a
bowel movement what action should the nurse implement? *** Send stool sample to the lab for a
guaiac test
A client is receiving mesalamine 800mg po TID Which assessment is most important for the nurse to
perform to assess the effectiveness of the medication? *** Bowel patterns
The nurse is assessing a client who reports falling two days ago and has a history of gouty arthritis that is
controlled with allopurinol the client states the left knee is swollen and extremely painful to touch which
instruction should the nurse include in the discharge teaching? *** Decrease consumption of red meat
and seafood
Before leaving the room of the confused client the nurse notes that a half bow knot was used to attach
the clients wrist restraints to the movable portion of the client's bed frame what action should the nurse
take before leaving the room? *** Ensured that the knot can quickly be released.
When caring for a client with a traumatic brain injury who had a craniotomy for increased and cranial
pressure the nurse assesses the client's using the glaucoma scale every two hours for the past eight
hours the client's black oak coma scale score has been 14 what does the glaucoma scale finding
indicates about the client? *** Neurologically stable without in dictation of an increased cranial
pressure
The nurse is managing the care of a client With cushings syndrome which intervention should the nurse
delegate to the unlicensed assistance personnel? SATA *** Report any client complaints of pain or
discomfort
weigh the client and report any weight gain
note and report that clients food and liquid intake during meals and snacks
