Hesi Exit (Nursing) | frequently tested HESI Questions | All you need to get that A.

Hesi Exit 3-A client who is one day postpartum tells nurse that her baby cannot catch onto the breast. The nurse determines that the client nipples are inverted. Which action should the nurse implement? a) Recommending using breast shield b) Offer supplemental formula feeding c) Teach about the use of a breast pump d) Encourage the use of ice on the areola Ans; A 6- The mother of a school age child calls the school to ask when her daughter can return to school after treatment for pediculosis capitis. What is the nurse best respond?(nits liendra) a) Until all lice are dead b) Until the epidemic in school subside c) Stay in home. ANS; A 10- The mother of the 7 month old bring the infant to the clinic because the skin in the diaper area is and red, but there are no blister or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a) Instruct the mother to change the child’s diaper more often. b) Tell the mother to cleanse with soap and water at each diaper change c) Encourage the mother to apply lotion with each diaper change. d) Ask the mother to decrease the infant’s intake of fruits for 24 hours ANS; A 12- When conducting discharge teaching of an older client. Which instruction regarding medication administration should the nurse include? a) The direction of the prescription container can be enlarge for including b) Medication should be moved for a similar condition that made... in the future c) Don’t share meds with family and friend (older people like to share medicine) ANS; C 15- A client was admitted to the cardiac observation unit 2 hour ago complaining of chest pain, On admission the client’s EKG showed bradycardia, ST depression, but no ventricular ectopic. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What interventions should the nurse perform? a) Notify the healthcare provider of the client’s increased chest pain and call for the defibrillator crash cart. b) Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzyme levels c) Administer prescribed morphine sulfate IV and provide oxygen at 2L/minute per nasal cannula d) Increase the peripheral IV flow rate to 175 ml/hr to prevent hypotension and shock ANS; C 16- Which intervention should the nurse include in the plan of care for tetanus.... a) Open the window shades toprovide natural light b) Encourage coughing and deep breathing. c) Minimize the amount of stimuli in the room d) Reposition from side to site every hour. ANS; B or C ojo, I put C 23- The nurse who is working on surgical unit receives change –of –shift report on a group of clients for the upcoming shift .The client with which description requires the most immediate attention by the nurse? a) Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-Pratt drain b) Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. c) Abdominal –resection 2 days ago with no drainage on dressing who has fever and chills. d) Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container. ANS; D , I put C 29- A client experiencing withdrawal from the Benzodiazepine alprasolan (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? a) Administer Narcan PRN protocol b) Obtain serum drug screen c) Instruct the family about withdrawal symptom d) Initiate seizure precautions ANS; D 34- The nurse is feeding a client who was admitted this morning with syncope and generalized weakness .The client has a history of aspiration and begins coughing while attempting to drink trough a straw. Which action should the nurse implement? a) Elevate the head of bed for 30 minutes after meal b) Perform oral care before meals c) Allow small amount of liquid with meals d) Provide nectar thickened liquids ANS; D, I put A 39- A HOME HEALTH NURSE IS VISITING A CLIENT WITH A HISTOY OF HEART FAILURE (HF) WHEN INTERVIEWING THE CLIENT, WHICH QUESTION PROVIDES THE MOST USEFUL INFORMATION FOR THE NURSE. A) – HAVE YOU HAD ANY HEADACHES LATELY? B) HOW MUCH CAFFEINE ARE YOU DRINKING C) HAVEYOU BEEN WEIGHING YOURSELF ONCE A MONTH D) HOW MANY PILLOWS DO YOU SLEEP ON AL NIGHT ANS; D 43- The nurse is preparing to conduct discharge teaching for a client who had an anaphylactic reaction following administration of ampicillin (omnipen-N). What instruction is essential for the nurse to provide this client prior discharge? A-Teach the client how to self-administer epinephrine in cases a reaction occur again B- Instruct the client to wear a medic-alert bracelet so penicillin will not be given again C- Tell the client to make medication with food to decrease will not be given again D- Inform the client that it is essential to take all of the prescribed ampicillin AnS: B 50- A CLIENT WITH A PRESCRIPTION FOR “DO NOT RESUSCITATE (DNR) BEGING TO MANISFEST SINGS OF IMPENDING DEATH. AFTER NOTIFYING OF THE CLIENT STATUS , WHAT PRIORITY ACTION SHOULD THE NURSE IMPLEMENT ? A) THE CLIENT NEED FOR PAIN MEDICATION SHOULD BE DETERMINED B) THE NURSE MANAGER SHOULD BE UPDATED ON THE CLIENT STATUS C) THE IMPENDING SINGOF DEATH SHOULD BE DOCUMENTED D) THE CLIENT STATUS SHOULD BE CONVEYED TO THE CHAPLAIN ANS; A One of them was which medication will you question to administer through a PEG tube - Only one that made sense to question was enteric coated aspirin because that one you cant crush 55-WHAT INSTRUCTION SHOULD THE NURSE PROVIDE TO A CLIENT WHO IS PREPARING TO HAVE A CYSTOSCOPY a) LAY PRONE FOR 24 HOURS AFTER THE PROCEDURE b) REPORT ANY PAINFUL URINATION, BLOOD URINE ,OR FEVER c) AVOID STRENUOUS ACTIVITY AND SPORTS FOR AT LEAST 2 WEEK d) REPORT ANY ALLERGIES TO SHELLFISH OR IODINE ANS; B 60- An adult male report that the last time he received penicillin he developed a severe maculapapular rash all over his chest. What information should the nurse provide to this client? A) Watch daily urine output and weight gain while taking antibiotic B) Be alert for possible cross-sensitivity to cephalosporin agents. C) Wear sun block and protective clothing to avoid exposure to sun ANS; B 61- A client who had a right hip replacement 3 days ago is pale has diminished breath sounds over the left lower field ,a temperature of 100.2 F, and oxygen saturation rate of 90% . The client is scheduled to be transferred to a skilled nursing facility tomorrow for rehabilitative critical pathway .Based on the client symptoms .What recommendation should the nurse give the healthcare provider? a) Reassess readiness for skilled nursing facility (SNF) transfer. b) Confer with family about home care planes. c) Arrange physical therapy for strengthening. d) Obtain specimens for culture analysis ANS; A 64- The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, mouth drooping, and aspiration pneumonia .What is the priority nursing assessment that she will be done before administering the med? a) Determine what side of the body is weak b) Auscultate breath sounds c) Obtain and record client vital sign d) Ask the client about soft food preferences ANS; A 65- A client with diagnostic of schizophrenia sits in the day room and fails to interact which others .which intervention is best for the nurse to implement with this client? a) Complete and assessment of social support b) Encourage the client to have lunch off the unit C) Give the client a schedule of planned daily activities d) Engage the client in a game of cards ANS; D 67- The nurse plans to collect a 24 hrs. urine specimen for creatinine clearance test .Which instructor should the nurse provide to the adult clients? a) Urinate immediately into the urinal, and the lab will collect the specimen every 6 hrs. for the next 24 hrs. . next 24hrs. c) For the next 24 hrs. Notify nurse when bladder is full and the nurse will collect cauterizedspecimen. d) Cleanse around the meatus, discard first portion of voiding and collect the rest in a sterilebottle. ANS; B 68-A child is brought to the clinic complaining of fever and joint pain ,and is diagnosed with rheumatic fever when planning care for this child ,What is the primary goal of nursing care ? a) Prevent cardiac damage (or Hemorrhage) b) Maintain joint mobility and function c) Reduce fever d) Maintain fluid nad electrolyte balance ANS-A, 73- In caring for a client with cushing syndrome, which serum lab value is most important for the nurse to monitor? a) Glucose b) Lactate c) Hemoglobin d) Creatinine ANS;A, Hyperglycemia 101- A client is scheduled for a laminectomy to treat lower back pain related to herniated intervertebral disk .While teaching a client the nurse say that tingling and numbness in the lower extremities sometimes occurs postoperatively as the result of which condition ? a) Is cause by minor injuries caused by positioning during surgery . b) Is caused by the manipultion of nerves and muscles during surgery . c) Is cause by the pressure on the nerves due to prolonged inmobility . d) Is caused by the effects of intrathecal anesthesia that resolve quickly ANS; B 113- To reduce staff nurse role ambiguity , which strategy should the nurse manager implement ? a) Review the staff nurse job description to ensure that it is clear, accurate, and current b) Assign each staff nurse a turn as the unit charge nurse on a regular, rotating basis c) Analyze the amount of overtime needed by the nursing staff to complete assignments d) Confirm that all of the staff nurses are being assigned to equal numbers of clients ANS; A 126-When preparing a client for discharge from the hospital following a cystectomy and urine diversion to treat bladder cancer .Which instruction is most important for the nurse to include in the discharge teaching plan? a) Frequent empty the bladder to avoid distention b) Follow instruction for self –care toileting c) Report any cloudy urine output d) Seek consueling for body image concerns. ANS; C 148-A child with heart failure is receiving the diuretic furosemide (Lasix) and has a serum potassium level of 3.0 mEq/L. Which assessment is most important for the nurse to obtain? a) Cardiac rhythm and heart rate b) Daily intake of foods rich in potassium c) Hourly urinary output d) Thirst and skin turgor ANS; A 171- A patient receiving alendronate sodium (Fosamax) to treat a newly diagnosed of osteoporosis. What instruction should the nurse include in the teaching plan? a) Eat within 30 min of taking the medication b) Take on an empty stomach with a full glass of water c) Consume a light snack with the medication d) Ingest an antacid 30 min prior of taking the tablet ANS: B 196-A MALE CLIENT WAS ADMITED TO THE CARDIAC CARE UNIT FOR OBSERVATION IS HAVING SPORADIC PREMATURE VENTRICULAR CONTRACTION (PVCS). WICH ACTIVITY ASOCIATED WITH THE T WAVE MAKE PVCS PARTICULARITY DANGEROUS WHEN THEY COinsider with THIS WAVEFORM A) DEPOLARIZATION B) REPOLARIZATION C) INCREASE IN CARDIAC OUTPUT D) ATRIAL CONTRACTION Ans; B 200-A MALE CLIENT WITH DEMENTIA WHO NEEDS ASSISTANCE WITH MEALS and activities OF DAILY LIVING OFTEN SCREEMS AT THE STAFF AND THE THREATENS TO HIT THOSE WHO COME NEAR HIM .WICH NURSING PROBLEM SHOULD BE INCLUDED IN THE THREATMENTS PLAN A)IMPAIRED VERBAL COMMUNICATION B)- RISK FOR ACUTE CONFUSION C)CAREGIVEN ROLE STRAIN D)- RISK FOR OTHER- DIRECTED VIOLENCE ANS- D 214-The nurse manager is concerned about the number of falls that have occurred on the site last month. Which action is most likely to decrease the number of falls? A) Obtain the evidence bead practice guidelines for falls prevention B) Place all clients on the unit regardless of age at risk for falls C) Determine if pain medication is related to those who fell D) Inquire about what other unit are doing to prevent falls. ANS: A 218- Teaching community:It said something like which of the following is most important to take into consideration when developing teaching strategies for a community? A- Prevalent learning style B- Internet access C- Median age D- Literacy level ANS: A, I put D 219- The nurse is auscultating a client’s lung sounds. Which description should the nurse use to document this sound? (audio) A- High pitched or fine crackles B- Rhonchi C- High pitched wheeze D- Stridor ANS: A, I put D, because my audio sounded like a Stridor, not sure if its right! 223- Patient with diabetes mellitus type I, the nurse notes that the respiratory rate have changed from 16 normal to 32 deep and the client has become lethargic. Which assessment data should the nurse obtain next? A- Breath sounds B- WBC C- Temperature D- Blood glucose ANS: D 226- An elderly female is admitted because of a change in her level of sensorium shift, the client attempts to get out of bed and falls, breaking her left hip. Buck traction applied to the left leg while waiting for surgery. Which intervention is most important to include in this clients plan of care? A- Evaluate her response to narcotic analgesia B- Ensure proper alignment of the leg in traction C- Place a pillow under the involved lower left leg D- Assess the skin under the traction moleskin ANS: D 242- A patient with IV line report painful at inicio on site?? What to do first? A. Stop infuse B. Remove iv C. Put in another arm D. Assess site for redness Correct Answer: A 244- Vietnams in mechanical soft diet /and regular diet and the family bring food ethnic .What do you do? A. Allow that client because Vietnam’s food is soft diet B. Ask for the meeting for the dietitian to include ethnic food selection according soft diet C. Tell the family that client is not able to eat that food from house. Correct Answer: B, I put A because it said allow him to eat the Vietnamese food as long as it is part of the mechanical sof t diet. 245. Patient with warfarin what teaching most important? A. Avoid all food containing vitamin K because is antagonist of warfarin. B. Take daily portion of green lefty vegetables to maintain the same consistent among. C. Eat 30 green leafy vegetables with milk. Correct Answer: A 249- A patient with thoracic aneurism what most to report and blood pressure 140/90 , temp 100.1, y se le habia dado hypertensive medication.? A. Report BP 120/80 B. Report rose urine in the catheter Correct Answer: B, it said amber urine so I put B 257- A client is scheduled for a laminectomy to treat lower back pain related to a herniated intervertebral disk. While conducting preoperative teaching, the nurse should teach the client that numbness and tingling in the lower extremities sometimes occurs postoperatively as the result of which condition? A. Effects of intrathecal anesthesia that resolve quickly B. Minor injuries caused by positioning during surgery C. Pressure on the nerves due to prolonged immobility D. Manipulation of nerves and muscles during surgery Correct Answer: D 1- Client in wrist restraint the nurse frist slides two fingers under the restraint and notes that the ties are secured to the side rail using a quick released tie .What the nurse do ? PHOTO R) Reposition the restraints ties, securing them to the bed frame. 3.2.1Older client that want to died and not want to in hospice but family member want something else? Ans: Arrange for meeting with client, family and Health care provide 9- An older client admitted to rehab following a CVA has aphasia, LS paralysis, difficulty swallowing. What is most important to include in plan of care? ANS: Obtain a consult with speech therapist 10- Picture- Choose Where the nurse has to place the diaphragm to take the Blood pressure in the leg? ANS: You have to point in the inside part of the thigh 11. Another picture with the ribs and you have to point the PMI (point of Maximal Impulse) -Left 4th to fifth intercoastal space midclavicular 14.12- A Stapedectomy ( ear surgery) child? Ans: Avoid sudden movement until dressing is of Note: Hearing will be muffled 21.2-Bucks traction = alignment leg in traction Bucks traction : immobilize to diminish mucle spasm, no more 8-10 pound, elevate the feet from the bed to provide the traction. Intervention: alignment of the body, weight hand free ans cannot touch the floor, do not move the weight bearing until you have a prescription. 32.3- A client was talking with the nurse and client was not putting attention what the nurse said. What action the nurse implement? Answer: Ask the client what he or she is thinking 36- A patient admitted with hypopituitarism and is hypotensive and diaphoretic, what would require immediate action by the nurse? ANS: lethargy , I put Bradycardia not sure if its right 52- Azithromycin lower lobe pneumonia and recurrent chlamydia ANS= use two form of contraception 56-Huntington disease Answer: Escort the patient to the cafeteria 58-A question about Unna boot: used for VENOUS STASIS ULCER Answer: Documentation, I put wound healing is in effect 62- Patient a new administration interview with family and he was not hearing well? Answer: Eliminate all noise Environment 73- Patient with a past allergy to penicillin ANS: Check for further cross allergy to cephalosporin antibiotics 8- Allergies to egg. (select all that apply) A. Place allergies in ID band B. Put in it flow sheet medication administration C. Medical record D. Document in the statement note E. Report to food services Correct Answers: A, B, C, E 14- The nurse is arranging home care for an older who has a new colostomy following a bowel resection three days ago. The client plans to live with a family member. Which action should the nurse implement? (Select all that Apply) A. Assess the client for self-care abilities. B. Provide pain medication instruction C. Request home safety inspection D. Call home care agency to set up oxygen. E. Teach care of ostomy to care provider Correct Answer: A, B, C, I put A, B , E not sure 4-Using the parkland formula for a patient with burns 4ml x Patients weight in kg which is 76kg x whatever % of burns, which is 40%. SO it is 4ml x 76kg x 40% = ANS: 12160