HESI FINAL EXAM VERSION 3
, Hesi Final Exam Version 3
1. A client who has been in active labor for 12 hours suddenly tells the nurse that she
has a strong urge to have a bowel movement. What action should the nurse take?
A. Allow the client to use a bedpan.
B. Explain the fetal head is descending.
C. Perform a sterile vaginal exam. <
D. Assist the client to the bathroom.
2. The nurse assesses a 78-year-old male client who has left sided heart failure.
Which symptoms would the nurse expect this client to exhibit?
A. Dyspnea, cough and fatigue. <
B. Hepatomegaly and distended neck veins.
C. Pain over the pericardium and friction rub.
D. Narrowing pulse pressure and distant heart sounds.
3. A female client comes to the clinic complaining of fatigue and inability to sleep
because she is the full-time caretaker for a 22-year-old son who was paralyzed by
a motor vehicle collision. She adds that her husband left her because he says he
can’t take her behavior anymore since all she does is care for their son. What
intervention should the nurse implement?
A. Teach the client to problem-solve for herself and establish her own priorities.
B. Schedule a home visit in the afternoon to assess the son and client’s role as
caregiver.
C. Provide feedback to the client about her atonement for guilt about her son’s
impairment.
D. Acknowledge the client’s stress and suggest that she consider respite care. <
4. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900
to a client with hypertension. At 0800, the nurse notes that the client’s telemetry
pattern shows a second-degree heart block with a ventricular rate of 50. What
action should the nurse take?
A. Administer the Toprol immediately and monitor the client carefully until the
heart rate increases.
B. Provide the dose of Toprol as scheduled and assign a UAP to monitor the
client’s BP q30 minutes.
C. Hold the scheduled dose of Toprol and notify the healthcare provider of the
telemetry pattern. <
D. Give the Toprol as scheduled if the client’s systolic blood pressure reading is
greater than 180.
5. A client who developed Syndrome of Inappropriate Antidiuretic Hormone
(SIADH) associated with small cell carcinoma of the lung is preparing for
discharge. When teaching the client about self-management with demeclocycline
, (Declomycin), the nurse should instruct the client to report which condition to the
healthcare provider?
A. Anxiety.
B. Insomnia.
C. Muscle cramping. <
D. Increased appetite.
6. In determining the client position for insertion of an indwelling urinary catheter, it
is most important for the nurse to recognize which client condition?
A. High urinary pH.
B. Fever.
C. Abdominal ascites.
D. Orthopnea. <
7. The nurse is reviewing a client’s electrocardiogram and determines that the PR
interval (PRI) is prolonged. What does this finding indicate?
A. Inability of the SA node to initiate an impulse at the normal rate.
B. Initiation of the impulse from a location outside the SA node.
C. Increased conduction time from the SA node to the AV junction. <
D. Interference with the conduction through one or both ventricles.
8. The nurse is teaching a male client with multiple sclerosis how to empty his
bladder using the Crede Method. When performing a return demonstration, the
client applies pressure to the umbilical area of his abdomen. What instruction
should the nurse provide?
A. Stroke the inner thigh below the perineum to initiate urinary flow.
B. Pour warm water over the external sphincter at the distal glans.
C. Apply downward manual pressure at the suprapubic region. <
D. Contract, hold, and then relax the pubococcygeal muscle.
A 35-year-old female client has just been admitted to the postanesthesia recovery unit
following a partial thyroidectomy. Which statement reflects the nurse’s accurate
understanding of the expected outcome for the client following this surgery?
A. Supplemental hormonal therapy will probably be unnecessary. <
B. The thyroid will regenerate to a normal size within a few years.
C. The client will be restricted from eating seafood.
D. The remainder of the thyroid will be removed at a later date.
9. A client with gestational diabetes, at 39-weeks gestation, is in the second stage of
labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia
is occurring. What intervention should the nurse implement first?
A. Lower the head of the bed and apply suprapubic pressure.
B. Encourage the client to move to a hands-and-knees position.
C. Prepare the client for an emergency cesarean birth.
D. Assist the client to sharply flex her thighs up against the abdomen. <
, 10. The nurse should observe most closely for drug toxicity when a client receives a
medication that has which characteristic?
A. Rapid onset of action.
B. Low bioavailability.
C. Narrow therapeutic index. <
D. Short half-life.
11. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which
assessment finding indicates to the nurse that the shunt is effective?
A. Decreased abdominal girth. <
B. Increased blood pressure.
C. Clear breath sounds.
D. Decreased serum albumin.
12. When finding a client sitting on the floor, the nurse calls for help from the
unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP
to do?
A. Check for any abrasions or bruises.
B. Help the client to stand.
C. Get a blood pressure cuff. <
D. Report the fall to the nurse-manager.
13. During the initial newborn assessment, the nurse finds that a newborn’s heart rate
is irregular. Which intervention should the nurse implement?
A. Notify the pediatrician immediately.
B. Teach the parents about congenital heart defects.
C. Document the finding in the infant’s record. <
D. Apply oxygen per nasal cannula at 3 L/min.
14. A client is diagnosed with a frontal lobe glioma, which is a benign brain tumor.
When teaching the client about the tumor, which information should the nurse
consider?
A. Surgery is not indicated unless the tumor becomes malignant.
B. Vision and hearing will be affected in the future.
C. If the tumor metastasizes, surgical intervention is necessary.
D. Personality changes or expressive aphasia are likely. <
15. A client who has suffered 3rd degree burns over 60% of the body is admitted to the
emergency department. The healthcare provider writes a prescription for “IV
Lactated Ringer’s 350 ml/hr”. Which intervention should the nurse implement?
A. Administer the Lactated Ringer’s at 350 ml/hr via gravity infusion.
B. Collaborate with the pharmacist to recalculate the infusion rate.
C. Obtain an intravenous infusion pump prior to administering the IV. <
D. Call the healthcare provider and question the prescription.
, Hesi Final Exam Version 3
1. A client who has been in active labor for 12 hours suddenly tells the nurse that she
has a strong urge to have a bowel movement. What action should the nurse take?
A. Allow the client to use a bedpan.
B. Explain the fetal head is descending.
C. Perform a sterile vaginal exam. <
D. Assist the client to the bathroom.
2. The nurse assesses a 78-year-old male client who has left sided heart failure.
Which symptoms would the nurse expect this client to exhibit?
A. Dyspnea, cough and fatigue. <
B. Hepatomegaly and distended neck veins.
C. Pain over the pericardium and friction rub.
D. Narrowing pulse pressure and distant heart sounds.
3. A female client comes to the clinic complaining of fatigue and inability to sleep
because she is the full-time caretaker for a 22-year-old son who was paralyzed by
a motor vehicle collision. She adds that her husband left her because he says he
can’t take her behavior anymore since all she does is care for their son. What
intervention should the nurse implement?
A. Teach the client to problem-solve for herself and establish her own priorities.
B. Schedule a home visit in the afternoon to assess the son and client’s role as
caregiver.
C. Provide feedback to the client about her atonement for guilt about her son’s
impairment.
D. Acknowledge the client’s stress and suggest that she consider respite care. <
4. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900
to a client with hypertension. At 0800, the nurse notes that the client’s telemetry
pattern shows a second-degree heart block with a ventricular rate of 50. What
action should the nurse take?
A. Administer the Toprol immediately and monitor the client carefully until the
heart rate increases.
B. Provide the dose of Toprol as scheduled and assign a UAP to monitor the
client’s BP q30 minutes.
C. Hold the scheduled dose of Toprol and notify the healthcare provider of the
telemetry pattern. <
D. Give the Toprol as scheduled if the client’s systolic blood pressure reading is
greater than 180.
5. A client who developed Syndrome of Inappropriate Antidiuretic Hormone
(SIADH) associated with small cell carcinoma of the lung is preparing for
discharge. When teaching the client about self-management with demeclocycline
, (Declomycin), the nurse should instruct the client to report which condition to the
healthcare provider?
A. Anxiety.
B. Insomnia.
C. Muscle cramping. <
D. Increased appetite.
6. In determining the client position for insertion of an indwelling urinary catheter, it
is most important for the nurse to recognize which client condition?
A. High urinary pH.
B. Fever.
C. Abdominal ascites.
D. Orthopnea. <
7. The nurse is reviewing a client’s electrocardiogram and determines that the PR
interval (PRI) is prolonged. What does this finding indicate?
A. Inability of the SA node to initiate an impulse at the normal rate.
B. Initiation of the impulse from a location outside the SA node.
C. Increased conduction time from the SA node to the AV junction. <
D. Interference with the conduction through one or both ventricles.
8. The nurse is teaching a male client with multiple sclerosis how to empty his
bladder using the Crede Method. When performing a return demonstration, the
client applies pressure to the umbilical area of his abdomen. What instruction
should the nurse provide?
A. Stroke the inner thigh below the perineum to initiate urinary flow.
B. Pour warm water over the external sphincter at the distal glans.
C. Apply downward manual pressure at the suprapubic region. <
D. Contract, hold, and then relax the pubococcygeal muscle.
A 35-year-old female client has just been admitted to the postanesthesia recovery unit
following a partial thyroidectomy. Which statement reflects the nurse’s accurate
understanding of the expected outcome for the client following this surgery?
A. Supplemental hormonal therapy will probably be unnecessary. <
B. The thyroid will regenerate to a normal size within a few years.
C. The client will be restricted from eating seafood.
D. The remainder of the thyroid will be removed at a later date.
9. A client with gestational diabetes, at 39-weeks gestation, is in the second stage of
labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia
is occurring. What intervention should the nurse implement first?
A. Lower the head of the bed and apply suprapubic pressure.
B. Encourage the client to move to a hands-and-knees position.
C. Prepare the client for an emergency cesarean birth.
D. Assist the client to sharply flex her thighs up against the abdomen. <
, 10. The nurse should observe most closely for drug toxicity when a client receives a
medication that has which characteristic?
A. Rapid onset of action.
B. Low bioavailability.
C. Narrow therapeutic index. <
D. Short half-life.
11. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which
assessment finding indicates to the nurse that the shunt is effective?
A. Decreased abdominal girth. <
B. Increased blood pressure.
C. Clear breath sounds.
D. Decreased serum albumin.
12. When finding a client sitting on the floor, the nurse calls for help from the
unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP
to do?
A. Check for any abrasions or bruises.
B. Help the client to stand.
C. Get a blood pressure cuff. <
D. Report the fall to the nurse-manager.
13. During the initial newborn assessment, the nurse finds that a newborn’s heart rate
is irregular. Which intervention should the nurse implement?
A. Notify the pediatrician immediately.
B. Teach the parents about congenital heart defects.
C. Document the finding in the infant’s record. <
D. Apply oxygen per nasal cannula at 3 L/min.
14. A client is diagnosed with a frontal lobe glioma, which is a benign brain tumor.
When teaching the client about the tumor, which information should the nurse
consider?
A. Surgery is not indicated unless the tumor becomes malignant.
B. Vision and hearing will be affected in the future.
C. If the tumor metastasizes, surgical intervention is necessary.
D. Personality changes or expressive aphasia are likely. <
15. A client who has suffered 3rd degree burns over 60% of the body is admitted to the
emergency department. The healthcare provider writes a prescription for “IV
Lactated Ringer’s 350 ml/hr”. Which intervention should the nurse implement?
A. Administer the Lactated Ringer’s at 350 ml/hr via gravity infusion.
B. Collaborate with the pharmacist to recalculate the infusion rate.
C. Obtain an intravenous infusion pump prior to administering the IV. <
D. Call the healthcare provider and question the prescription.
