Hesi Exit Exam 2 (1-147 Questions And
Answers)
1. Before leaving the room of a confused client, the nurse notes that a half
bow knot was used to attach the client's wrist restraints to the movable
portion of the client's bed frame. What action should the nurse take before
leaving the room?
a) Ensure that the restraints are snug against the client's wrists.
b) Move the ties so the restraints are secured to the side rails.
c) Ensure that the knot can be quickly released.
d) Tie the knot with a double turn or square knot.
Correct Ans ~ c) Ensure that the knot can be quickly released.
2. When gathering for a group therapy session at 1400 hours, a female client
complains to the nurse that a smoking break has not been allowed all day.
The nurse responds that 15 minute breaks were called over the unit intercom
after breakfast and after lunch. The nurse is using what communication
technique in responding to the client?
a) Doubt
b) Observation
c) Confrontation
d) Reflection
Correct Ans ~ d) Reflection
3. The nurse is interviewing a client with schizophrenia. Which client
behavior requires immediate intervention?
a) Lip smacking and frequent eye blinking
b) Shuffling gait and stooped posture
c) Rocks back and forth in the chair
d) Muscle spasms of the back and neck
Correct Ans ~ d) Muscle spasms of the back and neck
4. A female client with rheumatoid arthritis (RA) comes to the clinic
complaining of joint pain and swelling. The client has been taking prednisone
(Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the
client with self-management of her pain, which information should the nurse
obtain?
a) Presence of bruising, weakness, or fatigue
b) Therapeutic exercise included in daily routine.
c) Average amount of protein eaten daily
d) Existence of gastrointestinal discomfort
Correct Ans ~ b) Therapeutic exercise included in daily routine.
,5. The charge nurse of the Intensive Care Unit is making assignments for the
permanent staff and one RN who was floated from a medical unit. The client
with which condition is the best to assign to the float nurse?
a) Diabetic ketoacidosis and titrated IV insulin infusion
b) Emphysema extubated 3 hours ago receiving heated mist
c) Subdural hematoma with an intracranial monitoring device
d) Acute coronary syndrome treated with vasopressors
Correct Ans ~ a) Diabetic ketoacidosis and titrated IV insulin infusion
6. A client admitted to the emergency center had inspiratory and expiratory
wheezing, nasal flaring, and thick, tenacious sputum secretions observed
during the physical examination. Based on these assessment findings, what
classification of pharmacologic agents should the nurse anticipate
administering?
a) Beta blockers
b) Bronchodilators
c) Corticosteroids
d) Beta-adrenergics
Correct Ans ~ b) Bronchodilators
7. The nurse weighs a 6-month-old infant during a well baby check-up and
determines that the baby's weight has tripled compared to the birth weight
of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight.
What response should the nurse offer?
a) What food does your baby usually eat in a normal day?
b) What was the baby's weight at the last well-baby clinic visit?
c) The baby is below the normal percentile for weight gain
d) Your baby is gaining weight right on schedule
Correct Ans ~ What food does your baby usually eat in a normal day?
8. The home health nurse is assessing a male client who has started
peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants
immediate intervention by the nurse?
a) Finger stick blood glucose 120 mg/dL post exchange
b) Arteriovenous (AV) graft surgical site pulsations.
c) Anorexia and poor intake of adequate dietary protein
d) Cloudy dialysate output and rebound abdominal pain
Correct Ans ~ Cloudy dialysate output and rebound abdominal pain
9. A male client with renal cell carcinoma is returned to the unit following a
radical nephrectomy. The nurse notes that his vital signs and urine output
are within normal range, his bandage is dry, and the drain from the incision
site is producing a small amount of serasanguinous drainage. Which
intervention should the nurse implement?
a) Place a pressure bandage at the drainage site
b) Document assessment findings in the electronic medical record
,c) Monitor urinary catheter output for a decrease below 30 ml/hr
d) Notify surgeon of color and amount of wound drainage.
Correct Ans ~ Notify surgeon of color and amount of wound drainage
10. A client with chronic obstructive lung disease, who is receiving oxygen at
1.5 liters/minute by nasal cannula, is currently short of breath. What action
should the nurse take?
a) Ask the client to take short, rapid breaths
b) Instruct the client in pursed lip breathing
c) Increase oxygen to three liters/minute
d) Have the client breathe into a paper bag
Correct Ans ~ Instruct the client in pursed lip breathing
11. The nurse assesses a male client following surgery for a gunshot wound
to the abdomen and determines that his dressing is saturated with blood and
petechiae are on his extremities. His current blood pressure is 80/40, and his
heart rate is 130 beats/minute. Which laboratory finding confirms the
presence of disseminated intravascular coagulopathy (DIC)?
a) Low prothrombin time
b) Elevated fibrinogen
c) Positive d-Dimer
d) Normal hemoglobin
Correct Ans ~ Elevated fibrinogen
12. After a routine physical examination, the healthcare admits a woman
with a history of Systemic Lupus Erythematous (SLE) to the hospital because
she has 3+ pitting ankle edema and blood in her urine. Which assessment
finding warrants immediate intervention by the nurse?
a) Blood pressure 170/98
b) Joint and muscle aches
c) Urine output 300 ml/hr
d) Dark, rust-colored urine
Correct Ans ~ Urine output 300 ml/hr
13. In evaluating the effectiveness of a postoperative client's intermittent
pneumatic compression devices, which assessment is most important for the
nurse to complete?
a) Evaluate the client's ability to use an incentive spirometer
b) Monitor the amount of drainage from the client's incision
c) Observe both lower extremities for redness and swelling
d) Palpate all peripheral pulse points for volume and strength
Correct Ans ~ Monitor the amount of drainage from the client's incision
14. While caring for a toddler receiving oxygen (02) via face mask, the nurse
observes that the child's lips and nares are dry and cracked. Which
intervention should the nurse implement?
, a) Ask the mother what she usually uses on the child's lips and nose
b) Apply a petroleum jelly (Vaseline) to the child's nose and lips
c) Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips
d) Use a water soluble lubricant on affected oral and nasal mucosa
Correct Ans ~ Use a water soluble lubricant on affected oral and nasal
mucosa
15. A client develops urticaria on the trunk and neck shortly after a
secondary infusion of pipercillin (Zosyn) is initiated. In what order should the
nurse implement these interventions? (Arrange the actions in order of
priority, with the highest priority first, and least priority last or at the
bottom.)
a) Stop the infusion
b) Assess vital signs
c) Contact the healthcare provider
d) Document reaction to the drug
e) Initiate an adverse event report
Correct Ans ~
a) Stop the infusion
b) Assess vital signs
c) Contact the healthcare provider
d) Document reaction to the drug
e) Initiate an adverse event report
16. Which instruction is most important for the nurse to include in the
discharge teaching plan of a client who had a prostatectomy three days ago?
a) Ambulate and exercise as tolerated
b) Read written follow up instructions
c) Avoid lifting 20 pounds for 6 weeks
d) Increase fluid intake to one quart daily
Correct Ans ~ Avoid lifting 20 pounds for 6 weeks
17. Sublingual nitroglycerin is administered to a male client with instable
angina who complains of crushing chest pain. Five minutes later the client
becomes nauseated and his blood pressure drops to 60/40. Which
intervention should the nurse implement?
a) Give a PRN antiemetic medication
b) Infuse a rapid IV normal saline bolus
c) Begin external chest compressions
d) Administer second dose of nitroglycerin
Correct Ans ~ infuse a rapid IV normal saline bolus
19. The nurse is evaluating the health teaching of a female client with
condyloma acuminate. Which statement by the client indicates that teaching
has been effective?
Answers)
1. Before leaving the room of a confused client, the nurse notes that a half
bow knot was used to attach the client's wrist restraints to the movable
portion of the client's bed frame. What action should the nurse take before
leaving the room?
a) Ensure that the restraints are snug against the client's wrists.
b) Move the ties so the restraints are secured to the side rails.
c) Ensure that the knot can be quickly released.
d) Tie the knot with a double turn or square knot.
Correct Ans ~ c) Ensure that the knot can be quickly released.
2. When gathering for a group therapy session at 1400 hours, a female client
complains to the nurse that a smoking break has not been allowed all day.
The nurse responds that 15 minute breaks were called over the unit intercom
after breakfast and after lunch. The nurse is using what communication
technique in responding to the client?
a) Doubt
b) Observation
c) Confrontation
d) Reflection
Correct Ans ~ d) Reflection
3. The nurse is interviewing a client with schizophrenia. Which client
behavior requires immediate intervention?
a) Lip smacking and frequent eye blinking
b) Shuffling gait and stooped posture
c) Rocks back and forth in the chair
d) Muscle spasms of the back and neck
Correct Ans ~ d) Muscle spasms of the back and neck
4. A female client with rheumatoid arthritis (RA) comes to the clinic
complaining of joint pain and swelling. The client has been taking prednisone
(Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the
client with self-management of her pain, which information should the nurse
obtain?
a) Presence of bruising, weakness, or fatigue
b) Therapeutic exercise included in daily routine.
c) Average amount of protein eaten daily
d) Existence of gastrointestinal discomfort
Correct Ans ~ b) Therapeutic exercise included in daily routine.
,5. The charge nurse of the Intensive Care Unit is making assignments for the
permanent staff and one RN who was floated from a medical unit. The client
with which condition is the best to assign to the float nurse?
a) Diabetic ketoacidosis and titrated IV insulin infusion
b) Emphysema extubated 3 hours ago receiving heated mist
c) Subdural hematoma with an intracranial monitoring device
d) Acute coronary syndrome treated with vasopressors
Correct Ans ~ a) Diabetic ketoacidosis and titrated IV insulin infusion
6. A client admitted to the emergency center had inspiratory and expiratory
wheezing, nasal flaring, and thick, tenacious sputum secretions observed
during the physical examination. Based on these assessment findings, what
classification of pharmacologic agents should the nurse anticipate
administering?
a) Beta blockers
b) Bronchodilators
c) Corticosteroids
d) Beta-adrenergics
Correct Ans ~ b) Bronchodilators
7. The nurse weighs a 6-month-old infant during a well baby check-up and
determines that the baby's weight has tripled compared to the birth weight
of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight.
What response should the nurse offer?
a) What food does your baby usually eat in a normal day?
b) What was the baby's weight at the last well-baby clinic visit?
c) The baby is below the normal percentile for weight gain
d) Your baby is gaining weight right on schedule
Correct Ans ~ What food does your baby usually eat in a normal day?
8. The home health nurse is assessing a male client who has started
peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants
immediate intervention by the nurse?
a) Finger stick blood glucose 120 mg/dL post exchange
b) Arteriovenous (AV) graft surgical site pulsations.
c) Anorexia and poor intake of adequate dietary protein
d) Cloudy dialysate output and rebound abdominal pain
Correct Ans ~ Cloudy dialysate output and rebound abdominal pain
9. A male client with renal cell carcinoma is returned to the unit following a
radical nephrectomy. The nurse notes that his vital signs and urine output
are within normal range, his bandage is dry, and the drain from the incision
site is producing a small amount of serasanguinous drainage. Which
intervention should the nurse implement?
a) Place a pressure bandage at the drainage site
b) Document assessment findings in the electronic medical record
,c) Monitor urinary catheter output for a decrease below 30 ml/hr
d) Notify surgeon of color and amount of wound drainage.
Correct Ans ~ Notify surgeon of color and amount of wound drainage
10. A client with chronic obstructive lung disease, who is receiving oxygen at
1.5 liters/minute by nasal cannula, is currently short of breath. What action
should the nurse take?
a) Ask the client to take short, rapid breaths
b) Instruct the client in pursed lip breathing
c) Increase oxygen to three liters/minute
d) Have the client breathe into a paper bag
Correct Ans ~ Instruct the client in pursed lip breathing
11. The nurse assesses a male client following surgery for a gunshot wound
to the abdomen and determines that his dressing is saturated with blood and
petechiae are on his extremities. His current blood pressure is 80/40, and his
heart rate is 130 beats/minute. Which laboratory finding confirms the
presence of disseminated intravascular coagulopathy (DIC)?
a) Low prothrombin time
b) Elevated fibrinogen
c) Positive d-Dimer
d) Normal hemoglobin
Correct Ans ~ Elevated fibrinogen
12. After a routine physical examination, the healthcare admits a woman
with a history of Systemic Lupus Erythematous (SLE) to the hospital because
she has 3+ pitting ankle edema and blood in her urine. Which assessment
finding warrants immediate intervention by the nurse?
a) Blood pressure 170/98
b) Joint and muscle aches
c) Urine output 300 ml/hr
d) Dark, rust-colored urine
Correct Ans ~ Urine output 300 ml/hr
13. In evaluating the effectiveness of a postoperative client's intermittent
pneumatic compression devices, which assessment is most important for the
nurse to complete?
a) Evaluate the client's ability to use an incentive spirometer
b) Monitor the amount of drainage from the client's incision
c) Observe both lower extremities for redness and swelling
d) Palpate all peripheral pulse points for volume and strength
Correct Ans ~ Monitor the amount of drainage from the client's incision
14. While caring for a toddler receiving oxygen (02) via face mask, the nurse
observes that the child's lips and nares are dry and cracked. Which
intervention should the nurse implement?
, a) Ask the mother what she usually uses on the child's lips and nose
b) Apply a petroleum jelly (Vaseline) to the child's nose and lips
c) Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips
d) Use a water soluble lubricant on affected oral and nasal mucosa
Correct Ans ~ Use a water soluble lubricant on affected oral and nasal
mucosa
15. A client develops urticaria on the trunk and neck shortly after a
secondary infusion of pipercillin (Zosyn) is initiated. In what order should the
nurse implement these interventions? (Arrange the actions in order of
priority, with the highest priority first, and least priority last or at the
bottom.)
a) Stop the infusion
b) Assess vital signs
c) Contact the healthcare provider
d) Document reaction to the drug
e) Initiate an adverse event report
Correct Ans ~
a) Stop the infusion
b) Assess vital signs
c) Contact the healthcare provider
d) Document reaction to the drug
e) Initiate an adverse event report
16. Which instruction is most important for the nurse to include in the
discharge teaching plan of a client who had a prostatectomy three days ago?
a) Ambulate and exercise as tolerated
b) Read written follow up instructions
c) Avoid lifting 20 pounds for 6 weeks
d) Increase fluid intake to one quart daily
Correct Ans ~ Avoid lifting 20 pounds for 6 weeks
17. Sublingual nitroglycerin is administered to a male client with instable
angina who complains of crushing chest pain. Five minutes later the client
becomes nauseated and his blood pressure drops to 60/40. Which
intervention should the nurse implement?
a) Give a PRN antiemetic medication
b) Infuse a rapid IV normal saline bolus
c) Begin external chest compressions
d) Administer second dose of nitroglycerin
Correct Ans ~ infuse a rapid IV normal saline bolus
19. The nurse is evaluating the health teaching of a female client with
condyloma acuminate. Which statement by the client indicates that teaching
has been effective?
