HESI RN EXIT EXAM v1-7
A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal
mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are
negative. What information should the nurse include in the client’s teaching plan?
Further evaluation involving surgery may be needed
A client who recently underwear a tracheostomy is being prepared for discharge to home. Which
instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag
does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute.
What action should the nurse implement?
Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratory rate
is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm
should the nurse in0090pvestigate firs?
Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should
the nurse take first?
Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the
nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which
action should the nurse take first?
Inform the anesthesia care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To
determine if an S3 heart sound is present, what action should the nurse take first?
Listen with the bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance through her place of
employment. Which agency should the client be referred to by the employee health nurse for health
insurance needs?
,Medicare
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of
dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the
nurse?
Review with the client the need to avoid foods that are rich in milk and cream
A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns
to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he
has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the
need for hypertension control, the nurse should stress that an elevated BP places the client at risk for
which pathophysiological condition?
Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has
a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What
action should the nurse implement?
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12
days. Which assessment finding requires immediate follow-up?
Describes life without purpose
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack
should the nurse instruct the client to take with the tetracycline?
Toasted wheat bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse
that the client is experiencing a complication?
“I have a headache that gets worse when I sit up”
“I am having pain in my lower back when I move my legs”
“My throat hurts when I swallow”
“I feel sick to my stomach and am going to throw up”
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with
incontinence. Which action should the nurse implement?
,Obtain a clean catch mid-stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in
keeping with the child’s dietary restrictions. Which foods are contraindicated for this child?
Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating
nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should
the circulating nurse provide?
Direct the nurse to continue the surgical hand scrub for a 5 minute duration
Which breakfast selection indicates that the client understands the nurse’s instructions about the
dietary management of osteoporosis?
Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal
number of registered nurses will be working that shift. In planning assignments, which client should
receive the most care hours by a registered nurse (RN)?
An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter and soft
wrist restrains applied
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office.
Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the
child’s foot. Which action should the nurse implement first?
Cleanse the foot with soap and water and apply an antibiotic ointment
Provide teaching about the need for a tetanus booster within the next 72 hours.
have the mother check the child's temperature q4h for the next 24 hours
transfer the child to the emergency department to receive a gamma globulin injection
The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple
antibiotic ointment for two days, but there has been no improvement.” What instruction should the
nurse provide?
Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
, A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences
Bradycardia and constipation
Lethargy and lack of appetite
Muscle cramping and dry, flushed skin
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?
Obtain a list of medications taken for cardiac history
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D 5W at 300
mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric
value only.)
75
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x
25 = 75 ml/hour
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that
apply)
Fluid shifts from intravascular to interstitial area due to decreased serum protein
Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
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)
Murmur
Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence
created by the heart or valvular defect.
A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal
mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are
negative. What information should the nurse include in the client’s teaching plan?
Further evaluation involving surgery may be needed
A client who recently underwear a tracheostomy is being prepared for discharge to home. Which
instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag
does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute.
What action should the nurse implement?
Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratory rate
is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm
should the nurse in0090pvestigate firs?
Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should
the nurse take first?
Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the
nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which
action should the nurse take first?
Inform the anesthesia care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To
determine if an S3 heart sound is present, what action should the nurse take first?
Listen with the bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance through her place of
employment. Which agency should the client be referred to by the employee health nurse for health
insurance needs?
,Medicare
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of
dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the
nurse?
Review with the client the need to avoid foods that are rich in milk and cream
A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns
to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he
has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the
need for hypertension control, the nurse should stress that an elevated BP places the client at risk for
which pathophysiological condition?
Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has
a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What
action should the nurse implement?
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12
days. Which assessment finding requires immediate follow-up?
Describes life without purpose
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack
should the nurse instruct the client to take with the tetracycline?
Toasted wheat bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse
that the client is experiencing a complication?
“I have a headache that gets worse when I sit up”
“I am having pain in my lower back when I move my legs”
“My throat hurts when I swallow”
“I feel sick to my stomach and am going to throw up”
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with
incontinence. Which action should the nurse implement?
,Obtain a clean catch mid-stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in
keeping with the child’s dietary restrictions. Which foods are contraindicated for this child?
Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating
nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should
the circulating nurse provide?
Direct the nurse to continue the surgical hand scrub for a 5 minute duration
Which breakfast selection indicates that the client understands the nurse’s instructions about the
dietary management of osteoporosis?
Bagel with jelly and skim milk
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal
number of registered nurses will be working that shift. In planning assignments, which client should
receive the most care hours by a registered nurse (RN)?
An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter and soft
wrist restrains applied
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office.
Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the
child’s foot. Which action should the nurse implement first?
Cleanse the foot with soap and water and apply an antibiotic ointment
Provide teaching about the need for a tetanus booster within the next 72 hours.
have the mother check the child's temperature q4h for the next 24 hours
transfer the child to the emergency department to receive a gamma globulin injection
The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple
antibiotic ointment for two days, but there has been no improvement.” What instruction should the
nurse provide?
Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
, A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and
levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the
prescribed dosage is too high for this client? The client experiences
Bradycardia and constipation
Lethargy and lack of appetite
Muscle cramping and dry, flushed skin
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?
Obtain a list of medications taken for cardiac history
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D 5W at 300
mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric
value only.)
75
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x
25 = 75 ml/hour
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that
apply)
Fluid shifts from intravascular to interstitial area due to decreased serum protein
Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
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)
Murmur
Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence
created by the heart or valvular defect.
