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HESI RN EXIT Exam Questions and Verified
Answers
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 - Correct 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?" C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful." D) "Please print in the future so I do not have to spend extra time attempting to read your writing." - Correct 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? A) Age and knowledge level of the parents B) Proximity to emergency services C) Number of children in the home D) Age of children in the home - Correct 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 A) Administer a placebo B) Encourage increased fluid intake C) Administer the prescribed analgesia D) Recommend relaxation exercises for pain control - Correct answer C) Administer the prescribed analgesia 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 - Correct answer A) Respiratory rate of 42 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 - Correct 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) "Do not worry. Epilepsy can be treated with medications." B) "The seizure may or may not mean your child has epilepsy." C) "Since this was the first convulsion, it may not happen again." D) "Long term treatment will prevent future seizures." - Correct answer B) "The seizure may or may not mean your child has epilepsy."
The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C) Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings - Correct answer D) Pale, thin arms and legs, uninterested in surroundings As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss - Correct answer D) Hair loss While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degreesCelsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake - Correct answer B) Administer acetaminophen as ordered as this is normal at this time A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication - Correct answer B) Assess for dyspnea or stridor
Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn't hurt when I went. - Correct answer D) I went to the bathroom and my urine looked very red and it didn't hurt when I went. Which of these parents' comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? A) I noticed a little lump a little above the belly button. B) The baby seems hungry all the time. C) Mild vomiting that progressed to vomiting shooting across the room. D) Irritation and spitting up immediately after feedings. - Correct answer C) Mild vomiting that progressed to vomiting shooting across the room. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? A) Decreased cardiac output B) Tissue hypoxia C) Cerebral edema D) Reduced oxygen saturation - Correct answer B) Tissue hypoxia The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet A) High in carbohydrates and proteins
The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? A) Seizures B) Withdrawal C) Craving D) Marked tolerance - Correct answer B) Withdrawal Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner's injuries by A) Seeking medical help for the victim's injuries B) Minimizing the episode and underestimating the victim's injuries C) Contacting a close friend and asking for help D) Being very remorseful and assisting the victim with medical care - Correct answer B) Minimizing the episode and underestimating the victim's injuries A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago.During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath. "B) "I have been coughing up foul-tasting, brown, thick sputum. " C) "I have been sweating all day. "D) "I feel hot off and on." - Correct answer "B) "I have been coughing up foul-tasting, brown, thick sputum. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur
D) Split S2 - Correct answer A) S3 ventricular gallop Which of these observations made by the nurse during an excretory urogram indicate a complicaton? A) The client complains of a salty taste in the mouth when the dye is injected B) The client's entire body turns a bright red color C) The client states "I have a feeling of getting warm." D) The client gags and complains " I am getting sick." - Correct answer B) The client's entire body turns a bright red color A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest. "B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest. " D) "The tube will seal the hole in your lung." - Correct answer "B) "The tube will remove excess air from your chest." The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7. D) Serum potassium 6 mEq/L - Correct answer D) Serum potassium 6 mEq/L The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? A) Pallor B) Increased temperature C) Dyspnea
C) Compile a history of behavior patterns and developmental accomplishments D) Compare the child's behavior with classic signs and symptoms
- Correct answer C) Compile a history of behavior patterns and developmental accomplishments Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care? A) Measure head circumference B) Place in airborne isolation C) Provide passive range of motion D) Provide an over-the-crib protective top - Correct answer A) Measure head circumference A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values? A) Blood urea nitrogen B) Acid phosphatase C) Bilirubin D) Sedimentation Rate - Correct answer C) Bilirubin The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? A) May drink as much milk as desired B) Can have milk mixed with other foods C) Will benefit from fat-free cow's milk D) Should be limited to 3-4 cups of milk daily - Correct answer D) Should be limited to 3-4 cups of milk daily
The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client's behavior most likely indicates A) Neologisms B) Dissociation C) Flight of ideas D) Word salad - Correct answer C) Flight of ideas A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? A) Jumping rope B) Tying shoelaces C) Riding a tricycle D) Playing hopscotch - Correct answer C) Riding a tricycle A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is A) A transparent film dressing B) Wet dressing with debridement granules C) Wet to dry with hydrogen peroxide D) Moist saline dressing - Correct answer D) Moist saline dressing The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!" What would be the most appropriate next action? A) Leave the room and return five minutes later and give the medicine B) Explain to the child that the medicine must be taken now C) Give the medication to the father and ask him to give it
The nurse is caring for a client who requires a mechanical ventilator for breathing.The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator - Correct answer B) Perform a quick assessment of the client's condition The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? A) "I can't lie in 1 position for more than thirty minutes. "B) "I am allergic to shrimp." C) "I suffer from claustrophobia. "D) "I developed a severe headache after a spinal tap." - Correct answer "B) "I am allergic to shrimp." The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube - Correct answer A) Hold the tube feeding and notify the provider To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip
D) Withdraw catheter in a circular motion - Correct answer A) Apply suction for no more than 10 seconds An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) Administer the medication in 2 separate injections B) Give the medication in the dorsal gluteal site C) Call to get a smaller volume ordered D) Check with pharmacy for a liquid form of the medication skip - Correct answer A) Administer the medication in 2 separate injections The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) Enhance absorption of the medication B) Ensure that the entire dose of medication is given C) Provide more even distribution of the drug D) Prevent the drug from tissue irritation Skip - Correct answer D) Prevent the drug from tissue irritation Skip A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) Diaphoresis with decreased urinary output B) Increased heart rate with increase respirations C) Improved respiratory status and increased urinary output D) Decreased chest pain and decreased blood pressure - Correct answer C) Improved respiratory status and increased urinary output While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? A) "As you urinate more, you will need less medication to control fluid.
prescribed dosage is too high for this client? The client experiences: A. Bradycardia and constipation B. Lethargy and lack of appetite C. Muscle cramping and dry, flushed skin D. Palpitations and shortness of breath - Correct answer D. Palpitations and shortness of breath A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? - Correct answer Obtain a list of medications taken for cardiac history The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) - Correct answer A. Fluid shifts from intravascular to interstitial area due to decreased serum protein B. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen C. Increased circulating aldosterone levels that increase sodium and water retention The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) - Correct answer Murmur A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? A) Transparent dressing
B) Dry sterile dressing with antibiotic ointment C) Wet to dry dressing D) Occlusive moist dressing - Correct answer D) Occlusive moist dressing A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? A) Cartoon stickers B) Large wooden puzzle C) Blunt scissors and paper D) Beach ball - Correct answer B) Large wooden puzzle A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the A) Yang, the positive force that represents light, warmth, and fullness B) Yin, the negative force that represents darkness, cold, and emptiness C) Use of improper hot foods, herbs and plants D) A failure to keep life in balance with nature and others - Correct answer B) Yin, the negative force that represents darkness, cold, and emptiness A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? A) "There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns that can be dealt with." C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure - Correct answer D) Note patterns of increased blood pressure The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? A) Schedule the therapy thirty minutes after meals B) Teach the child not to cough during the treatment C) Confine the percussion to the rib cage area D) Place the child in a prone position for the therapy - Correct answer C) Confine the percussion to the rib cage area Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs - Correct answer A) Orthostatic hypotension is a common side effect The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots B) Medium banana C) Naval orange D) Baked potato - Correct answer D) Baked potato An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?
A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids - Correct answer B) Check the client's gag reflex The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence - Correct answer C) Reposition every two hours A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client - Correct answer C) A client who had 3 incontinent diarrhea stools Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight - Correct answer B) Obtain a health and dietary history After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
