HESI MILESTONE EXIT EXAM V2-WITH 100%
ACCURATE SOLUTIONS-
HESI Exit V2
1. The nurse knows that which statement by the mother indicates that the mother understands
safety precautions with her four month-old infant and her 4year-old child?
the air
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on ablanket to play with my 4 year old
while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocksstuck up in
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old abottle in
the kitchen
while I make supper."
The correct answer is D: "I have the four year-old hold andhelp feed the four month-old a bottle in
the kitchen
2. Upon completing the admission documents, the nurse learns that the87 year-old client A) Record
the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary
does not have an advance directive. What action should the nurse take?
The correct answer is B: Give information about advance directives
3. A nurse administers the influenza vaccine to a client in a clinic. Within15 minutes
,after
the immunization was given, the client complains of itchy and wateryeyes, increased anxiety, and
difficulty breathing. The nurse expects that the first action inthe sequence of
care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
The correct answer is B: Administer epinephrine 1:1000 asordered .
4. Which of these children at the site of a disaster at a child day carecenter would the A) An infant
with intermittent bulging anterior fontanel betweencrying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with anupper leg fracture
D) A school-age child with singed eyebrows and hair on the armsThe correct answer is B: A toddler
with severe deep abrasions over 98% of the body .
triage nurse put in the "treat last" category?
5. When admitting a client to an acute care facility, an identificationbracelet is sent up A) Change
whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement issupplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client
with the admission form. In the event these do not match, the nurse’sbest action is to
,The correct answer is C: notify the admissions office andwait to apply the bracelet
6. The nurse is having difficulty reading the health care provider's writtenorder that was A) Leave the
order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification
written right before the shift change. What action should be taken?
The correct answer is D: Call the provider for clarification
7. An adult client is found to be unresponsive on morning rounds. Afterchecking for
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway
responsiveness and calling for help, the next action that should be takenby the nurse is
to:
The correct answer is D: open the client''s airway
8. A client has an order for 1000 ml of D5W over an 8 hour period. Thenurse discovers A) Ask the
client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs
that 800 ml has been infused after 4 hours. What is the priority nursingaction?
The correct answer is D: Auscultate the lungs
, 9. Following change-of-shift report on an orthopedic unit, which clientshould the nurse A) 16 year-
old who had an open reduction of a fractured wrist 10hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycleaccident
C) 72 year-old recovering from surgery after a hip replacement 2hours ago
D) 75 year-old who is in skin traction prior to planned hip pinningsurgery. The correct answer is C: 72
year-old recovering from surgery after ahip replacement 2 hours ago
see first?
10. A nurse observes a family member administer a rectal suppository byhaving the client lie on the
left side for the administration. The family memberpushed the suppository until the finger went up
to the second knuckle. After 10minutes the client A) Why don’t we now have the client turn back to
the left side.
B) That was done correctly. Did you have any problems with theinsertion?
C) Let’s check to see if the suppository is in far enough.
was told by the family member to turn to the right side and the client didthis. What is the
appropriate comment for the nurse to make?
D) Did you feel any stool in the intestinal tract?
The correct answer is B: That was done correctly. Did youhave any problems with the insertion?
11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) has A) airborne
precautions
B) droplet precautions
C) contact precautions
D) compromised host precautions
died. Which type of precautions is the appropriate type to use whenperforming postmortem care?
The correct answer is C: contact precautions
ACCURATE SOLUTIONS-
HESI Exit V2
1. The nurse knows that which statement by the mother indicates that the mother understands
safety precautions with her four month-old infant and her 4year-old child?
the air
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on ablanket to play with my 4 year old
while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocksstuck up in
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old abottle in
the kitchen
while I make supper."
The correct answer is D: "I have the four year-old hold andhelp feed the four month-old a bottle in
the kitchen
2. Upon completing the admission documents, the nurse learns that the87 year-old client A) Record
the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary
does not have an advance directive. What action should the nurse take?
The correct answer is B: Give information about advance directives
3. A nurse administers the influenza vaccine to a client in a clinic. Within15 minutes
,after
the immunization was given, the client complains of itchy and wateryeyes, increased anxiety, and
difficulty breathing. The nurse expects that the first action inthe sequence of
care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
The correct answer is B: Administer epinephrine 1:1000 asordered .
4. Which of these children at the site of a disaster at a child day carecenter would the A) An infant
with intermittent bulging anterior fontanel betweencrying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with anupper leg fracture
D) A school-age child with singed eyebrows and hair on the armsThe correct answer is B: A toddler
with severe deep abrasions over 98% of the body .
triage nurse put in the "treat last" category?
5. When admitting a client to an acute care facility, an identificationbracelet is sent up A) Change
whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement issupplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client
with the admission form. In the event these do not match, the nurse’sbest action is to
,The correct answer is C: notify the admissions office andwait to apply the bracelet
6. The nurse is having difficulty reading the health care provider's writtenorder that was A) Leave the
order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification
written right before the shift change. What action should be taken?
The correct answer is D: Call the provider for clarification
7. An adult client is found to be unresponsive on morning rounds. Afterchecking for
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway
responsiveness and calling for help, the next action that should be takenby the nurse is
to:
The correct answer is D: open the client''s airway
8. A client has an order for 1000 ml of D5W over an 8 hour period. Thenurse discovers A) Ask the
client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs
that 800 ml has been infused after 4 hours. What is the priority nursingaction?
The correct answer is D: Auscultate the lungs
, 9. Following change-of-shift report on an orthopedic unit, which clientshould the nurse A) 16 year-
old who had an open reduction of a fractured wrist 10hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycleaccident
C) 72 year-old recovering from surgery after a hip replacement 2hours ago
D) 75 year-old who is in skin traction prior to planned hip pinningsurgery. The correct answer is C: 72
year-old recovering from surgery after ahip replacement 2 hours ago
see first?
10. A nurse observes a family member administer a rectal suppository byhaving the client lie on the
left side for the administration. The family memberpushed the suppository until the finger went up
to the second knuckle. After 10minutes the client A) Why don’t we now have the client turn back to
the left side.
B) That was done correctly. Did you have any problems with theinsertion?
C) Let’s check to see if the suppository is in far enough.
was told by the family member to turn to the right side and the client didthis. What is the
appropriate comment for the nurse to make?
D) Did you feel any stool in the intestinal tract?
The correct answer is B: That was done correctly. Did youhave any problems with the insertion?
11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) has A) airborne
precautions
B) droplet precautions
C) contact precautions
D) compromised host precautions
died. Which type of precautions is the appropriate type to use whenperforming postmortem care?
The correct answer is C: contact precautions
