HESI Exit Exam 1 Graded A+ 2025

1. A male client admitted the morning of his scheduled surgery tells the PN that he drank water last night. What intervention will the PN implement first? Determine the amount of water and exact time it was taken. 2. A client receives ondansetron prior to chemotherapy treatment. How should the PN evaluate this medication? Monitor the client for nausea or vomiting following the treatment. 3. During morning rounds a client is admitted with OCD is in the...of the same table. What intervention should the PN implement when approached? Provide time for the behavior then guide the client to other activities. 4. The PN is caring for an older adult client who is confused and spends...factor contributes to an increased risk for impaired skin integrity for this client? Has increasing episodes of urinary incontinence. 5. The PN determines that a client with cirrhosis is experiencing peripheral .... Take? Protect the clients’ feet from injury. 7. A client is admitted to the postoperative surgical unit after a left lobectomy with two chest tubes......observes the water-sealed chambers, set and prescribed suction of 20cm water .. what action should the PN implement? Maintain system integrity and to promote lung expansion. 8. Photo of chest and locating apical HR. Just below the left nipple. 9. At the end of a 12-hour shift the PN observes the urine in a client’s drainage. What action should the PN take next? Note the most recent white blood count. 10. A client with a compound fracture of the left ankle is being discharged with a below the knee cast .... PN provide to the client prior to discharge? Never scratch under the cast. 11. Thirty minutes after receiving IV morphine, a postoperative male client continues to rate his pain.. what action should the PN implement first? Implement complementary pain relief methods. 12. A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in. .. with one or two word responses. The morning the PN observes that he .. Which intervention is most important for the PN to implement? Measure appropriate vital signs. 13. The PN is assisting an unsteady client to ambulate from the bed to the bath. . client loses balance and falls onto the bedside table. What action should the PN take first? Stay with the client and call for assistance. 14. The PN is assisting a female client to obtain a voided specimen for Uri...meatus. Which intervention is performed next? Initiate the urine stream? 15. An 8-year-old is placed in 90-90 traction for a fractured femur that resulted from.. further action by the PN? Weights are touching the foot of the bed. 16. The PN is reviewing diet instructions with a female client who has hyper ..she has increased her intakes of protein and calories. What action should the PN take? Encourage the client to continue the dietary changes she has made 17. A 3-year-old child returns to the pediatrician’s office for a postoperative visit after having...procedure. The PN should expect to observe which behavior that indicates... Plays doctor and nurse with the dolls 18. The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis and is preparing for discharge from the hospital. What... -why the fluid measurements need to be recoded -which food types are included when measuring fluid take -what container to use for the most accurate measurement 19. A male client receives a prescription for 3,000 mg of medication daily, which is available...taken twice daily in equal dosages. How many tablets should the PN.. ? 3. 20. A mother brings her 5-year-old child to the clinic for school physical examinations. Which assessment... PN that intergenerational violence may be occurring in the home? -The 6-year-old son hits his younger sister during the interview -the 10-year-old daughter has circular burns on her trunk and legs -the 3-year-old has multiple bruises on the chest and both legs 21. A client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 ml per hour is...1200 the PN notes that there are 750 ml of solution remaining. At what time should the nurse expect to discontinue the intravenous therapy? 1700. 22. The PN is caring for a client who had a total laryngectomy, left radical neck dissection... Client is receiving nasogastric tube feedings via an internal pump. Today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding? Gastric residual volumes. 23. A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take? Ensure that all the areolar tissue of the nipple is in the infant’s mouth. 24. Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? Deltoid. 25. Before inserting medication into a client’s vagina, what instructions should the pn. Urinate until bladder is empty. 26. An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which information is best for the PN to provide? A history of untreated gonorrhea can lead to PID 27. A 28-year-old client is in active labor and complains of a cramp in her leg. What intervention should the PN implement? Extend the leg and flex the foot? 28. A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort? Wear a supportive bra at all times. 29. A client with schizophrenia reports auditory hallucinations when admitted to the hospital. PN to include in the assessment of this client? "What are the voices uttering?" 30. A young adult male tells the PN he has declared to change his hours at work so that he can...his community. Which stage of Maslow's development is this young adult attempting to achieve? Self-actualiztion. 31. A female client arrives to the clinic for an annal physical examination. When reviewing...the PN that she takes herbs for high blood pressure instead of the prescribed. Important for the PN to reinforce with the client? Explain risks associated with using herbs instead of the prescribed antihypertensives. 32. A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client “This type…hospital" what intervention should the PN implement? Act as the clients advocate when discussing the issue with the HCP. 33. The PN is caring for a client receiving chemotherapy who has thrombocytopenia. Important to include in the nursing care plan? Watch the client for abnormal bleeding 34. A client is transferred to the surgical unit from the intensive care unit after evacuation of bilateral. Primary observation should the PN monitor? Neuro-vital signs related to bleeding and intracranial pressure. 35. The PN is working the day shift in a long-term facility and is preparing. Delegate to the UAP to perform during the change of. Total the clients PO intake, fill the water pitchers, empty urinals and catheter bags. 36. While taking the vital signs of a older male client who takes psychotropic medication...uncontrollable hand movements ad is excessively blinking his eyes, which information. Screening for tardive dyskinesia. 37. A female client tells the PN that her hemorrhoids are inflamed and hurt. The PN to implement to complete a focused assessment? Position client in left lateral position to inspect perianal area for fissures or sacs. 38. The PN is implementing the plan of care for a client who admits having...indicates the highest risk for the client acting on these suicidal thoughts? Begins to show signs of improvement. 39. The PN observes that a male clients urinary catheter drainage tubing is...the attached to the bed frame. What action should the PN implement? Observe the appearance of the urine in the drainage tubing. 40. A 150-pound adult client with Partial-thickness burns over 40% of the body. Hospital burn unit. Which observation is most important for the PN to report? Urinary output of 20 ml/hr. 41. The PN notes that an elderly client has developed nonproductive...the previous day. Vital signs are temperature 99.8 F; pulse 94; respirations 22; and BP... Important for the PN to implement? Report the findings to the charge nurse. 42. The PN is making shift assignment at an extended care rehabilitation...assign to the UAP. -Toileting assistance for a client receiving therapy after a total hip replacement -daily skin care for a client with a descending double barrel colostomy -morning care for a client with a staph wound infection 43. A client is complaining of a tightening sensation in the fingers, nose tip and ear lobes...24...PN should be prepared to implement what measure first? Obtain prescribed calcium gluconate for tetany. 44. A client’s chief complaint is being able to swallow only small bites of solid food...PN should assess for what additional information? History of alcohol and tobacco use. 45. An adult female client with type 1 diabetes mellitus is receiving 35 units of NPH insulin...PN document as evidence that the amount of insulin is inadequate. Consecutive evening serum glucose readings of >260 mg/dl. 46. The PN is assigned the care of four clients on a medical-surgical...prioritize client assessments -A client who is admitted with a suspected ruptured appendix -A client who is post-lumbar puncture is reporting a severe headache -An older male adult with Alzheimer’s who wanders out of his room -A postoperative client who needs reinforcement of discharge instruction 47. The partner refuses to go. The PN suspects the injuries may be the result of... Arrange to take the client to the operating room holding area for privacy. 48. The PN is caring for a client whose urine drug screen is positive for...exhibit during cocaine withdraw. Powerful craving for more 49. The PN is with a client when the health care provider explains that the tumor. Later in the morning the client asks the PN "What do the letters T, N, M: star for? The letters stand for tumor size, node involvement, and metastasis. 50. Following discharge teaching, a male client with duodenal ulcer tells the nurse he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow- up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream. 51. An adolescent male with severe acne recently started treatment with isotretinoin, a form of Vitamin A. During a follow up clinic appointment, which assessment is most important for the PN to complete? Ask about occurrence and frequency of nosebleeds 52. The PN is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to reinforce in this client plan of care? Interventions to decrease emotional stress. 53. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the PN, who is taking the client the clients vital signs. What action should the PN implement? Reinforce the need for extra rest periods and plenty of sleep. 54. The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond? Affirm the importance of rest to promote liver healing. 55. When the PN plans daily care for a group pf client, which client should the PN see first due to the risk of complication? An older client with a stroke who is febrile and confused. 56. Which foot care instructions is most important for the PN to reinforce that minimizes a long- term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)? Report any food injury or sore that does not readily heal. 57. During a clinic visit for a sore throat a client’s basal metabolic panel reveals a serum potassium of 3.0bml q/L. Which action should the PN recommend to the client based on this finding? Increase intake of dried peaches and apricots. 58. A client with a fractured left hip fracture is in Bucks’ traction. The PN should expect the client to exhibit which outcome? The left foot is warm to touch with a palpable dorsalis pedis pulse 59. When entering the room of an older female resident of a long-term care facility, the PN finds one of the male residents in bed with her. What action should the PN take? Close the door and report the finding to the charge nurse. 60. Prior to giving digoxin, the PN assesses that a 2-month-old infants heart rate is 120 beats/min. Based on this finding what action should the PN take? Give the medication and document the heart rate. 61. A resident of a long-term care facility who has a drainage stage 2 pressure ulcer receives a prescription for sterile, warm, moist compress q12 hours for 20 minutes to the site. What precautions should the PN take when performing this procedure? Select all that apply -remove soiled dressings with procedure gloved and don sterile gloves for moist dressing application -place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the dressed site -pour warmed sterile solution to an open sterile dressing tray that contained sterile gauze pads 62. A male client who is diagnosed with schizophrenia is taking an antipsychotic medication and calls the psychiatric clinic. The client tells the PN that he is achy and stiff, has a temperature of 103.4 F and is sweating. How should the PN respond to this client? Direct the client to obtain immediate transportation to the emergency center. 63. The Glasgow coma scale is being used to monitor a client in the critical care unit. The scale is used to evaluate what client status? Level of conscious. 64. A client is diagnosed with hyperthyroidism. Which symptoms should the PN expect this client to exhibit? Muscle cramping and dry flushed skin 65. The PN administers an antibiotic to a client with a respiratory tract infection...evaluate the medications effectiveness, which laboratory values should the PN monitor? B,d ABD. 66. To obtain an estimate of a client’s systolic blood pressure, what action should the PN take first? Palpate the client’s brachial pulse. 67. A client reports feeling numbness and tingling in extremities. What action should the PN implement? Review the client’s serum electrolyte levels. 68. Immediately after birth, which nursing intervention has the highest priority for the newborn infant? Preventing heat loss and neonatal cold stress. 69. The PN overhears a female client with Cushing’s syndrome tell her family in a very loud and angry voice to leave her room and not come back. The response by the PN is based on recognizing which common manifestation of the syndrome? Mood alterations. 70. A 0800 a client’s apical pulse rate is 98 beats/minute> Four hours later the apical pulse rate is 54 beats/minute. What action should the PN take next? Determine the level of consciousness. 71. After three weeks of antibiotic therapy, a child who weighs 55 pounds develops painful oral lesions, so the heal care provider prescribes acyclovir (Zovirax) 20 mg/kg daily. How many mg should the PN administer to this child? 500 72. The PN is assisting a client to the bathroom after right cataract extraction. The client has an eye shield over the right eye. How should the PN asset the client during ambulation? Stand in front of the client and lead the client forward to the bathroom. 73. Which client information is most important for the PN to consider when providing instructions to the UAP about providing morning care to a postoperative client? Urinary output of 50 ml/hour. 74. A male client who was admitted with gangrene of the right lower extremity is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the PN take first? Encourage the client’s wife to express concerns. 75. After report, the PN receives the laboratory values for four clients. Which client requires the pns immediate intervention? A client who is trembling and has a glucose level of 50. 76. Based on the nursing diagnosis of "risk for infection" which intervention should the PN implement when providing care for an elderly client with urinary incontinence. Maintain standard precautions. 77. During recovery after the delivery of a normal infant a client is receiving...ringers 1000 ml with oxytocin 20 units. The PN should evaluate the client for which therapeutic response? Stimulation of uterine contractions. 78. The spouse of a hospitalized client asks the PN for acetaminophen for a tension headache. Which action should the PN take? Explain that medication can only be provided to clients. 79. A 5-year-old child is admitted with full thickness burns over 30% of the total body surface areas (TBSA). After fluid replacement therapy is initiated, which finding should the PN use to evaluate the effectiveness of the therapy? Urine output. 80. When the PN attempts to assist an 18-year-old female client with mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and yells at the PN "get out of here! Ill get up when I'm ready!" which response is best for the PN to make? I know you feel very angry about the pain of ambulation, but this is a necessary part of getting well. 81. A client with hypertension complains of a persistent dry cough. The PN should tell the client that this is a common side effect of which daily medication? Quinapril. 82. The PN enters the room of a client who is disoriented and has a wrist restraint secured as seen in the picture what action should the PN take? Photo is of hospital bed and restraint Is on the bed frame in a bow tie. Use a full knot to secure the restraint line. 83. The PN views the mid-line episiotomy of a client who reports pain in her stitches. What action should the PN take first? Observe suture line for separation and hematoma formation. 84. A new mother asks the PN about an area of swelling on her baby head that lies across the suture line near the posterior fontanel. How should the PN respond? Caput succedaneum will be absorbed and causes no problem. 85. The PN obtains a finger stick glucose for a client with type 1 diabetes mellitus who is conscious and demonstrating hand tremors and shaking. The PN reports the clients result of 55 mg/dl to the nurse. What action should the PN implement next? Provide the client with a glass of milk and crackers. 86. A client who is primigravida at term comes to the prenatal clinic and tells the PN that she is having contractions every 5 minutes. The PN monitors the client for 1 hour using a external fetal monitor and determines that the clients contractions are 7 to 15 minutes apart lasting 20-30 seconds with mild intensity by palpation. What action should the PN take? Send the client home and instruct her to call the clinic when her contractions are 5 minutes apart for one hour. 87. The PN plans to evaluate an adult’s response to a prescription for colchicine. Last week the client was seen in the clinic for pain in the great left toe, which was the result of an acute attack of gout. Which data should the PN obtain to evaluate the therapeutic effectiveness of this medication? Pain scale level during walking. 88. The PN is caring for a client who was recently diagnosed with hepatitis B virus (HBV). The PN observes that the client’s urine is the color of dark tea. What action should the PN take? Encourage increased oral fluid intake. 89. In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the PN take? Use a gloved finger to rub the suspension over the infected area. 90. While the PN and UAP are turning a client with an abdominal incision, the client’s incision eviscerates. Which task is best for the PN to assign to the UAP? Gather supplies. 91. A client develops generalized edema associated with chronic kidney disease (CKD). The PN understands the formation of the edema is the result of which physiological process? Plasma protein losses resulting in decreased oncotic pressure within the vessels. 92. The PN and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement? Demonstrate to the UAP how to approach the client from the clients left side. 93. An older adult female is admitted with syncope and laboratory findings indicate that her hemoglobin is 8.0 grams /dl. She has a recent history of headaches and frequent falls. Admission prescription orders include continuation of all home medications. Which medication should the PN withhold until consulting with the charge nurse? Aspirin. 94. The PN is planning care for a client who has generalized tonic colonic seizures and is vomiting and having frequent diarrhea stools. To reduce the risk of injury to this client which nursing measurements should the PN implement? Axillary temperatures and padded side rails. 95. When assessing an adult male who present at the community health clinic with a history of hypertension the nurse notes that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflux disease and depression. Which interventions is most important for the PN to implement? Review the clients use of over the counter (OTC) medications. 96. A client with Alzheimer’s disease (AD) is receiving trazadone (Desyrel) a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client’s mood and sleep patterns are improved but there is no change in cognitive ability. How should the nurse respond to this information? Confirm that the desired effect of the medication has been achieved? 97. A client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the PN implement in response to the client’s refusal? Emphasize the importance of active foot flexion. 98. After applying alcohol-based hand rub to the palms of the hand and rubbing peps together what action should the PN take next? Place hands on top of each other and interlace fingers. 99. A new mother is bottle feeding instead of breastfeeding the PN should instruct the two most effective way to deal with breast engorgement and discomfort is to? Wear a supportive bra at all times. 100. Because of staffing shortages the charge nurse assigns a PN to perform a skill which the PN is not yet certified to perform what is the best response by the PN? I am uncomfortable performing a skill which I am not certified. 101. A client recovering from a stroke is learning how to use a cane. How should it be placed? On the stronger side of the body. 102. A client with schizophrenia is withdrawn isolates himself in the day room and answers questions with one- or two-word responses which intervention is most important? Measure appropriate vital signs. 103. While performing the apical pulse of an adult male client the PN notes that the point of maximal impulse is located at the 4th intercostals space medial to the midclavicular line what is the assessment for? Expected finding. 104. A client with type 2 diabetes becomes unresponsive and says I'm not feeling right which action should the PN take? Give 4 ounces of apple juice. 105. A new mother is breastfeeding her newborn for the first time and complains of nipple pain when the baby sucks. What should the nurse tell the mom? Ensure that all the areola tissue of the nipple is in the infant’s mouth. 106. A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug? Provide oral care. 107. The PN is caring for a client in bucks’ tract what is the priority goal for the client in traction? Maintain straight body alignment. 108. Which site should the PN use when administering RHO D. Deltoid. 109. Client with Huntington’s disease starts jerking around while the family is there what should the PN do? Offer emotional support to the family. 110. When should a person use additional birth control precautions? When taking antibiotics for an infection. 111. Client who has four gold seed implants on a chest wall tumor is on radiation precautions what basic precautions should the PN nurse observe when administering direct client care? Minimal time maximum distance and protective shielding. 112. Client voiding small amounts every 24 hours The catheterized volume determines the need to reinsert the indwelling catheter. 113. Based on the principle of asepsis the PN should consider which situation to be sterile? An open Foley catheter kit set up on a table at the PN waist level. 114. A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client? Measure all emesis accurately. 115. Single mother of a child with head injury comes crying to the clinic what should the PN tell her? This must seem overwhelming to you right now. 116. On admission to the medical unit a client who is homeless and has a history of HIV with persistent cough? Erythema and indurations of 5mm at site. 117. When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given In the computer. What action should the PN take? Contact the medication nurse to clarify the findings.