Exam (elaborations) - 2020 - 2021 hesi rn exit exam
v4 full 160 answers
2020/2021 HESI RN EXIT EXAM
V4 FULL 160 ANSWERS
1. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for
eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value only.) 200ml . 25 ml of
full strength feeding mixed with 25ml of water provided 50ml of half strength. 25ml × 8 hours= 200m
2. An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? Apply an
external condom catheter
3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to
allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for
prayer. What action should the nurse implement? Reschedule administration of the antibiotic until after he
completes his prayers
4. UAP using a hand sanitzers that is alcohol for 2 minutes- tell that hand sanitizer use is less > 2min
5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The child
weighs 44 pounds. How many mg of the medication should the nurse administer. Answer: 800 Rationale: First,
convert the child’s weight to kg: 44 pounds divided by
2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg
6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather
than trickles from the vagina. The uterine fundus is firm and the client’s vital signs are pulse 88 beats/minute;
respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take next?
Compare current vital signs with previous vital signs
7. A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye.
Which action should the school nurse take? Have the parent take the child for emergency help
8. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre behavior,
and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of
“Altered thought processes, secondary to” what condition? Postpartum psychosis
9. The nurse identifies a priority diagnosis of, “Altered comfort related to menstrual cramps” for a 25-year-old
female client. Which self-care activity should the nurse emphasize in the client’s teaching plan? Regular
aerobic exercise.
10. Psych/Alcohol/Tylenol overdose antidote – Give Mucomyst
11. Medical Surgical/Laxative abuses – Patient -taking Milk of Magnesium
12. Spiritual/Documentation- Native American – Allow pt’s family to stay in the room
13. Leadership- Interpreter informed consent – Pt should sign the consent
, 14. Geriatrics/Emergency Rib fractures fall – Pulmonary embolism
15. A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which
instruction should the nurse provide to the client’s family? Involve the client in usual at home activities
16. Upon assessment, the nurse discovers that a postpartum client has persistent red lochia.
Which of the following does this assessment finding suggest to the nurse? Coagulation disorders
17. The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is
drained. What action should the nurse complete first? Assess vital signs.
18. After administering a medication through a nasogastric tube connected to suction, what action should the
nurse take first? Clamp the tube
19. The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000. What
should the nurse implement? Determine if Client B has two units of packed cells available in the blood bank.
20. Triage question with a train wreck The psychiatric nurse is called to a train derailment that was likely caused
by a terrorist bomb. In triaging those in need of immediate care, what is the priority ranking for these cases?
(arrange these cases in order or priority with the top item requiring the most immediate care and the
bottom item requiring the least priority care) A mother and father have just arrived on the . A crying child
being held by another passenger. A woman sitting on the ground with a blanket. A middle-aged man who is
wandering around
21. (arrange in order) = middle age woman bleeding- woman w/ blanket- child crying- mother and father. (Mine
didn’t have a middle age woman bleeding, instead it had an old man wandering and correct order is:
wandering old man, woman w/blanket, man holding baby, and mother & father)
22. The nurse in the emergency department is using the simple triage and rapid transport (START) system to
assess victims of a hurricane. Which statement correctly describes a yellow disaster tag? A yellow disaster
tag means critical injuries and require immediate intervention.
23. What makes a baby frontal bulge or rises= crying
24. Which of the following is a nursing intervention for a 3-year-old client who is going in for sugery in 8 hours
that has an order for fluid restriction? Do not allow the child to drink fluids
25. The ear, where do u pull to give a ear drop= it a picture so look it up online (KNOW CHILD & ADULT) (pull the
pinnae top side of ear; u can look at a picture to see exactly where pinnae is) (Mine had a picture of ear and
put it on the lobule of the pinnae it is the ear lobe). The eye picture asked to find the macula or the fovea
centralis (there are 2 prominent spots on the eye – choose the DARK spot to the left not the spot where the
light is)
26. Know your serum levels? K- 3.5-5.1, Na – 135-145, Ca 9-11, BUN – 10-20
27. When to use drug for motion sickness drug question – Take Zofran 4 hours before going on trip via sea.
v4 full 160 answers
2020/2021 HESI RN EXIT EXAM
V4 FULL 160 ANSWERS
1. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for
eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value only.) 200ml . 25 ml of
full strength feeding mixed with 25ml of water provided 50ml of half strength. 25ml × 8 hours= 200m
2. An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? Apply an
external condom catheter
3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to
allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for
prayer. What action should the nurse implement? Reschedule administration of the antibiotic until after he
completes his prayers
4. UAP using a hand sanitzers that is alcohol for 2 minutes- tell that hand sanitizer use is less > 2min
5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The child
weighs 44 pounds. How many mg of the medication should the nurse administer. Answer: 800 Rationale: First,
convert the child’s weight to kg: 44 pounds divided by
2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg
6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather
than trickles from the vagina. The uterine fundus is firm and the client’s vital signs are pulse 88 beats/minute;
respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take next?
Compare current vital signs with previous vital signs
7. A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye.
Which action should the school nurse take? Have the parent take the child for emergency help
8. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre behavior,
and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of
“Altered thought processes, secondary to” what condition? Postpartum psychosis
9. The nurse identifies a priority diagnosis of, “Altered comfort related to menstrual cramps” for a 25-year-old
female client. Which self-care activity should the nurse emphasize in the client’s teaching plan? Regular
aerobic exercise.
10. Psych/Alcohol/Tylenol overdose antidote – Give Mucomyst
11. Medical Surgical/Laxative abuses – Patient -taking Milk of Magnesium
12. Spiritual/Documentation- Native American – Allow pt’s family to stay in the room
13. Leadership- Interpreter informed consent – Pt should sign the consent
, 14. Geriatrics/Emergency Rib fractures fall – Pulmonary embolism
15. A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which
instruction should the nurse provide to the client’s family? Involve the client in usual at home activities
16. Upon assessment, the nurse discovers that a postpartum client has persistent red lochia.
Which of the following does this assessment finding suggest to the nurse? Coagulation disorders
17. The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is
drained. What action should the nurse complete first? Assess vital signs.
18. After administering a medication through a nasogastric tube connected to suction, what action should the
nurse take first? Clamp the tube
19. The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000. What
should the nurse implement? Determine if Client B has two units of packed cells available in the blood bank.
20. Triage question with a train wreck The psychiatric nurse is called to a train derailment that was likely caused
by a terrorist bomb. In triaging those in need of immediate care, what is the priority ranking for these cases?
(arrange these cases in order or priority with the top item requiring the most immediate care and the
bottom item requiring the least priority care) A mother and father have just arrived on the . A crying child
being held by another passenger. A woman sitting on the ground with a blanket. A middle-aged man who is
wandering around
21. (arrange in order) = middle age woman bleeding- woman w/ blanket- child crying- mother and father. (Mine
didn’t have a middle age woman bleeding, instead it had an old man wandering and correct order is:
wandering old man, woman w/blanket, man holding baby, and mother & father)
22. The nurse in the emergency department is using the simple triage and rapid transport (START) system to
assess victims of a hurricane. Which statement correctly describes a yellow disaster tag? A yellow disaster
tag means critical injuries and require immediate intervention.
23. What makes a baby frontal bulge or rises= crying
24. Which of the following is a nursing intervention for a 3-year-old client who is going in for sugery in 8 hours
that has an order for fluid restriction? Do not allow the child to drink fluids
25. The ear, where do u pull to give a ear drop= it a picture so look it up online (KNOW CHILD & ADULT) (pull the
pinnae top side of ear; u can look at a picture to see exactly where pinnae is) (Mine had a picture of ear and
put it on the lobule of the pinnae it is the ear lobe). The eye picture asked to find the macula or the fovea
centralis (there are 2 prominent spots on the eye – choose the DARK spot to the left not the spot where the
light is)
26. Know your serum levels? K- 3.5-5.1, Na – 135-145, Ca 9-11, BUN – 10-20
27. When to use drug for motion sickness drug question – Take Zofran 4 hours before going on trip via sea.
