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HESI EXIT V2
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.
2. The nurse is assigned to a client who has heart failure. During the
morning rounds the nurse sees the client develop sudden anxiety,
diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally.
Which nursing intervention should be performed first?
A) Take the client's vital signs
B) Place the client in a sitting position with legs dangling
C) Contact the health care provider
D)Administer the PRN anti-anxiety agent
3. 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
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B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven
4. 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
5. 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."
.
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6. 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
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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?"
7. In planning care for a 6 month-old infant, what must the nurse provide to
assist in the development of trust?
A) Food
B) Warmt
h C)
Security
D) Comfort
8. 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?"
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