EXIT HESI
The nurse performs a prescribed neurological check at the beginning of the shift on a
client who was admitted to the hospital with a subarachnoid brain attack (stroke). The
client's Glasgow Coma Scale (GCS) score is 9. What information is most important for
the nurse to determine?
• The client's previous GCS score
• When the client's stroke symptoms started
• If the client is oriented to time
• The client's blood pressure and respiration raTe - Answer A
Rationale: The normal GCS is 15, and it is most important for the nurse to
determine if it abnormal score a sign of improvement or a deterioration in the
client's condition
Based on principles of asepsis, the nurse should consider which circumstance to be
sterile?
• One inch- border around the edge of the sterile field set up in the operating room
• A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
• An open sterile Foley catheter kit set up on a table at the nurse waist level
• Sterile syringe is placed on sterile area as the nurse riches over the sterile field. -
Answer C
Rationale: A sterile package at or above the waist level is considered sterile. The
edge of sterile field is contaminated which include a 1-inch border (A). A sterile
objects become contaminated by capillary action when sterile objects become in
contact with a wet contaminated surface.
An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers
spasms when taking the blood pressure using the same arm. After confirming the
presence of spams what action should the nurse take?
• Ask the UAP to take the blood pressure in the other arm
• Tell the UAP to use a different sphygmomanometer.
• Review the client's serum calcium level
• Administer PRN antianxiety medication. - Answer C
Rationale: Trousseau's sign is indicated by spasms in the distal portion of an
extremity that is being used to measure blood pressure and is caused by
hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.
A 56-years-old man shares with the nurse that he is having difficulty making decision
about terminating life support for his wife. What is the best initial action by the nurse?
• Provide an opportunity for him to clarify his values related to the decision
• Encourage him to share memories about his life with his wife and family
• Advise him to seek several opinions before making decision
• Offer to contact the hospital chaplain or social worker to offer support. - Answer A
Rationale: When a client is faced with a decisional conflict, the nurse should first
provide opportunities for the client to clarify values important in the decision. The
rest may also be beneficial once the client as clarified the values that are
important to him in the decision-making process
,EXIT HESI
A client is being discharged home after being treated for heart failure (HF). What
instruction should the nurse include in this client's discharge teaching plan?
• Weigh every morning
• Eat a high protein diet
• Perform range of motion exercises
• Limit fluid intake to 1,500 ml daily - Answer A
A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum
potassium level 3.0 mEq/L. Which assessment is most important for the nurse to
obtain?
• Cardiac rhythm and heart rate.
• Daily intake of foods rich in potassium.
• Hourly urinary output
• Thirst ad skin turgor. - Answer A
The nurse note a depressed female client has been more withdrawn and non
communicative during the past two weeks. Which intervention is most important to
include in the updated plan of care for this client?
• Encourage the client's family to visit more often
• Schedule a daily conference with the social worker
• Encourage the client to participate in group activities
• Engage the client in a non-threatening conversation. - Answer D
Rationale: Consistent attempts to draw the client into conversations which focus on
non-threatening subjects can be an effective means of eliciting a response, thereby
decreasing isolation behaviors. There is not sufficient data to support the
effectiveness of A as an intervention for this client. Although B may be indicated,
nursing interventions can also be used to treat this client. C is too threatening to
this client.
A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel)
subcutaneously once weekly. The nurse should emphasize the importance of
reporting problem to the healthcare provider?
• Headache
• Joint stiffness
• Persistent fever
• Increase hunger and thirst - Answer C
Rationale: Enbrel decrease immune and inflammatory responses, increasing the
client's risk of serious infection, so the client should be instructed to report a
persistent fever, or other signs of infection to the healthcare provider.
The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment
finding indicates that the client understands long- term control of diabetes?
• The fating blood sugar was 120 mg/dl this morning.
• Urine ketones have been negative for the past 6 months
• The hemoglobin A1C was 6.5g/100 ml last week
• No diabetic ketoacidosis has occurred in 6 months. - Answer C
,EXIT HESI
Rationale: A hemoglobin A1C level reflects he average blood sugar the client had
over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the client
understand long-term diabetes control. Normal value in a diabetic patient is up to
6.5 g/100 ml.
A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted
with osteomyelitis. The healthcare provider collects home aspirate specimens for culture
and sensitivity and applies a cast to the adolescent's lower leg. What action should the
nurse implement next?
• Administer antiemetic agents
• Bivalve the cast for distal compromise
• Provide high- calorie, high-protein diet
• Begin parenteral antibiotic therapy - Answer D
Rationale: The standard of treatment for osteomyelitis is antibiotic therapy and
immobilization. After bond and blood aspirate specimens are obtained for culture
and sensitivity, the nurse should initiate parenteral antibiotics as prescribed.
A male client receives a thrombolytic medication following a myocardial infarction. When
the client has a bowel movement, what action should the nurse implement?
• Send stool sample to the lab for a guaiac test
• Observe stool for a day-colored appearance.
• Obtain specimen for culture and sensitivity analysis
• Asses for fatty yellow streaks in the client's stool. - Answer A
Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac
(occult blood test) test of the stool should be evaluated to detect bleeding in the
intestinal tract
In early septic shock states, what is the primary cause of hypotension?
• Peripheral vasoconstriction
• Peripheral vasodilation
• Cardiac failure
• A vagal response - Answer B
Rationale: Toxins released by bacteria in septic shock create massive peripheral
vasodilation and increase microvascular permeability at the site of the bacterial
invasion.
A client diagnosed with calcium kidney stones has a history of gout. A new
prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which
client medication should the nurse bring to the healthcare provider's attention?
• Allopurinol (Zyloprim)
• Aspirin, low dose
• Furosemide (lasix)
• Enalapril (vasote) - Answer A
A male client's laboratory results include a platelet count of 105,000/ mm3 Based on
this finding the nurse should include which action in the client's plan of care?
, EXIT HESI
• Cluster care to conserve energy
• Initiate contact isolation
• Encourage him to use an electric razor
• Asses him for adventitious lung sounds - Answer C
Rationale: This client is at risk for bleeding based on his platelet count (normal
150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for
shaving, should be encouraged to reduce the risk of bleeding.
A client is admitted to the hospital after experiencing a brain attack, commonly
referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a
referral for speech therapy if the client exhibits which finding?
• Abnormal responses for cranial nerves I and II
• Persistent coughing while drinking
• Unilateral facial drooping
• Inappropriate or exaggerated mood swings - Answer B
At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews
the client's medical record. Based on date contained in the record, what action should
the nurse take before assisting the client with ambulation:
• Remove sequential compression devices.
• Apply PRN oxygen per nasal cannula.
• Administer a PRN dose of an antipyretic.
• Reinforce the surgical wound dressing. - Answer A
Rationale: Sequential compression devices should be removed prior to ambulation
and there is no indication that this action is contraindicated. The client's oxygen
saturation levels have been within normal limits for the previous four hours, so
supplemental oxygen is not warranted.
Which assessment finding for a client who is experiencing pontine myelinolysis
should the nurse report to the healthcare provider?
• Sudden dysphagia
• Blurred visual field
• Gradual weakness
• Profuse diarrhea - Answer A
A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after
receiving chemotherapy. The client has saline lock and is sleeping quietly without any
restlessness. The nurse caring for the client is not certified in chemotherapy
administration. What action should the nurse take?
• Ask a chemotherapy-certified nurse to administer the Zofran
• Administer the Zofran after flushing the saline lock with saline
• Hold the scheduled dose of Zofran until the client awakens
• Awaken the client to assess the need for administration of the Zofran. - Answer B
Rationale: Zofran is an antiemetic administered before and after chemotherapy to
prevent vomiting. The nurse should administer the antiemetic using the accepter
technique for IV administration via saline lock. Zofran is not a chemotherapy drug
The nurse performs a prescribed neurological check at the beginning of the shift on a
client who was admitted to the hospital with a subarachnoid brain attack (stroke). The
client's Glasgow Coma Scale (GCS) score is 9. What information is most important for
the nurse to determine?
• The client's previous GCS score
• When the client's stroke symptoms started
• If the client is oriented to time
• The client's blood pressure and respiration raTe - Answer A
Rationale: The normal GCS is 15, and it is most important for the nurse to
determine if it abnormal score a sign of improvement or a deterioration in the
client's condition
Based on principles of asepsis, the nurse should consider which circumstance to be
sterile?
• One inch- border around the edge of the sterile field set up in the operating room
• A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
• An open sterile Foley catheter kit set up on a table at the nurse waist level
• Sterile syringe is placed on sterile area as the nurse riches over the sterile field. -
Answer C
Rationale: A sterile package at or above the waist level is considered sterile. The
edge of sterile field is contaminated which include a 1-inch border (A). A sterile
objects become contaminated by capillary action when sterile objects become in
contact with a wet contaminated surface.
An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers
spasms when taking the blood pressure using the same arm. After confirming the
presence of spams what action should the nurse take?
• Ask the UAP to take the blood pressure in the other arm
• Tell the UAP to use a different sphygmomanometer.
• Review the client's serum calcium level
• Administer PRN antianxiety medication. - Answer C
Rationale: Trousseau's sign is indicated by spasms in the distal portion of an
extremity that is being used to measure blood pressure and is caused by
hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.
A 56-years-old man shares with the nurse that he is having difficulty making decision
about terminating life support for his wife. What is the best initial action by the nurse?
• Provide an opportunity for him to clarify his values related to the decision
• Encourage him to share memories about his life with his wife and family
• Advise him to seek several opinions before making decision
• Offer to contact the hospital chaplain or social worker to offer support. - Answer A
Rationale: When a client is faced with a decisional conflict, the nurse should first
provide opportunities for the client to clarify values important in the decision. The
rest may also be beneficial once the client as clarified the values that are
important to him in the decision-making process
,EXIT HESI
A client is being discharged home after being treated for heart failure (HF). What
instruction should the nurse include in this client's discharge teaching plan?
• Weigh every morning
• Eat a high protein diet
• Perform range of motion exercises
• Limit fluid intake to 1,500 ml daily - Answer A
A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum
potassium level 3.0 mEq/L. Which assessment is most important for the nurse to
obtain?
• Cardiac rhythm and heart rate.
• Daily intake of foods rich in potassium.
• Hourly urinary output
• Thirst ad skin turgor. - Answer A
The nurse note a depressed female client has been more withdrawn and non
communicative during the past two weeks. Which intervention is most important to
include in the updated plan of care for this client?
• Encourage the client's family to visit more often
• Schedule a daily conference with the social worker
• Encourage the client to participate in group activities
• Engage the client in a non-threatening conversation. - Answer D
Rationale: Consistent attempts to draw the client into conversations which focus on
non-threatening subjects can be an effective means of eliciting a response, thereby
decreasing isolation behaviors. There is not sufficient data to support the
effectiveness of A as an intervention for this client. Although B may be indicated,
nursing interventions can also be used to treat this client. C is too threatening to
this client.
A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel)
subcutaneously once weekly. The nurse should emphasize the importance of
reporting problem to the healthcare provider?
• Headache
• Joint stiffness
• Persistent fever
• Increase hunger and thirst - Answer C
Rationale: Enbrel decrease immune and inflammatory responses, increasing the
client's risk of serious infection, so the client should be instructed to report a
persistent fever, or other signs of infection to the healthcare provider.
The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment
finding indicates that the client understands long- term control of diabetes?
• The fating blood sugar was 120 mg/dl this morning.
• Urine ketones have been negative for the past 6 months
• The hemoglobin A1C was 6.5g/100 ml last week
• No diabetic ketoacidosis has occurred in 6 months. - Answer C
,EXIT HESI
Rationale: A hemoglobin A1C level reflects he average blood sugar the client had
over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the client
understand long-term diabetes control. Normal value in a diabetic patient is up to
6.5 g/100 ml.
A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted
with osteomyelitis. The healthcare provider collects home aspirate specimens for culture
and sensitivity and applies a cast to the adolescent's lower leg. What action should the
nurse implement next?
• Administer antiemetic agents
• Bivalve the cast for distal compromise
• Provide high- calorie, high-protein diet
• Begin parenteral antibiotic therapy - Answer D
Rationale: The standard of treatment for osteomyelitis is antibiotic therapy and
immobilization. After bond and blood aspirate specimens are obtained for culture
and sensitivity, the nurse should initiate parenteral antibiotics as prescribed.
A male client receives a thrombolytic medication following a myocardial infarction. When
the client has a bowel movement, what action should the nurse implement?
• Send stool sample to the lab for a guaiac test
• Observe stool for a day-colored appearance.
• Obtain specimen for culture and sensitivity analysis
• Asses for fatty yellow streaks in the client's stool. - Answer A
Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac
(occult blood test) test of the stool should be evaluated to detect bleeding in the
intestinal tract
In early septic shock states, what is the primary cause of hypotension?
• Peripheral vasoconstriction
• Peripheral vasodilation
• Cardiac failure
• A vagal response - Answer B
Rationale: Toxins released by bacteria in septic shock create massive peripheral
vasodilation and increase microvascular permeability at the site of the bacterial
invasion.
A client diagnosed with calcium kidney stones has a history of gout. A new
prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which
client medication should the nurse bring to the healthcare provider's attention?
• Allopurinol (Zyloprim)
• Aspirin, low dose
• Furosemide (lasix)
• Enalapril (vasote) - Answer A
A male client's laboratory results include a platelet count of 105,000/ mm3 Based on
this finding the nurse should include which action in the client's plan of care?
, EXIT HESI
• Cluster care to conserve energy
• Initiate contact isolation
• Encourage him to use an electric razor
• Asses him for adventitious lung sounds - Answer C
Rationale: This client is at risk for bleeding based on his platelet count (normal
150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for
shaving, should be encouraged to reduce the risk of bleeding.
A client is admitted to the hospital after experiencing a brain attack, commonly
referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a
referral for speech therapy if the client exhibits which finding?
• Abnormal responses for cranial nerves I and II
• Persistent coughing while drinking
• Unilateral facial drooping
• Inappropriate or exaggerated mood swings - Answer B
At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews
the client's medical record. Based on date contained in the record, what action should
the nurse take before assisting the client with ambulation:
• Remove sequential compression devices.
• Apply PRN oxygen per nasal cannula.
• Administer a PRN dose of an antipyretic.
• Reinforce the surgical wound dressing. - Answer A
Rationale: Sequential compression devices should be removed prior to ambulation
and there is no indication that this action is contraindicated. The client's oxygen
saturation levels have been within normal limits for the previous four hours, so
supplemental oxygen is not warranted.
Which assessment finding for a client who is experiencing pontine myelinolysis
should the nurse report to the healthcare provider?
• Sudden dysphagia
• Blurred visual field
• Gradual weakness
• Profuse diarrhea - Answer A
A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after
receiving chemotherapy. The client has saline lock and is sleeping quietly without any
restlessness. The nurse caring for the client is not certified in chemotherapy
administration. What action should the nurse take?
• Ask a chemotherapy-certified nurse to administer the Zofran
• Administer the Zofran after flushing the saline lock with saline
• Hold the scheduled dose of Zofran until the client awakens
• Awaken the client to assess the need for administration of the Zofran. - Answer B
Rationale: Zofran is an antiemetic administered before and after chemotherapy to
prevent vomiting. The nurse should administer the antiemetic using the accepter
technique for IV administration via saline lock. Zofran is not a chemotherapy drug
