2021 HESI EXIT V4

2021 HESI EXIT V4 1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained in correct body alignment. B) Be sure the traction weights touch the end of the bed. C) Adjust the head and foot of the bed for the child's comfort D) Release the traction for 15-20 minutes every 6 hours PRN. The correct answer is A: Make certain the child is maintained in correct body alignment. 2. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider? A) Height and weight percentiles vary widely B) Growth pattern appears to have slowed C) Recumbent and standing height are different D) Short term weight changes are uneven The correct answer is A: Height and weight percentiles vary widely 3. The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? A) Teach the parents how to perform cardiopulmonary resuscitation B) Recommend that the parents give in when he holds his breath to prevent anoxia C) Advise the parents to ignore breath holding because breathing will begin as a reflex D) Instruct the parents on how to reason with the child about possible harmful effects The correct answer is C: Advise the parents to ignore breath holding because breathing will begin as a reflex 4. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? A) "My pain is deep in my chest behind my sternum." B) "When I sit up the pain gets worse." C) "As I take a deep breath the pain gets worse." D) "The pain is right here in my stomach area." The correct answer is A: "My pain is deep in my chest behind my sternum." . 5. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory? A) "Name the year." "What season is this?" (pause for answer after each question) B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number." C) "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?" The correct answer is C: "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." 6. 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 The correct answer is C: Security