Hesi Exit Exam 3 – (201-300 Questions And Answers)
201. A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4
days. Which finding indicates to the nurse that the medication is effective?
Correct Ans ~ Reduced level of pain.
202. A group of nurse-managers is asked to engage in a needs assessment for a piece of
equipment that will be expensed to the organization's budget. Which question is most
important to consider when analyzing the cost-benefit for this piece of equipment?
Correct Ans ~ How many departments can use this equipment?
203. While receiving a male postoperative client's staples de nurse observe that the client's
eyes are closed and his face and hands are clenched. The client states, "I just hate having
staples removed". After acknowledgement the client's anxiety, what action should the
nurse implement? Correct Ans ~ Attempt to distract the client with general conversation.
Rational: Distract is an effective strategy when a client experience anxiety during an
uncomfortable procedure. (A & D) increase the client's anxiety.
204. A male client is admitted for the removal of an internal fixation that was inserted for
the fracture ankle. During the admission history, he tells the nurse he recently received
vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound
infection. Which action should the nurse take? (Select all that apply.)
Correct Ans ~ Collect multiple site screening culture for MRSA.
Place the client on contact transmission precautions.
Continue to monitor for client sign of infection.
Rationale: Until multi-site screening cultures come back negative (A), the client should be
maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid
(Zyvox), a broad spectrum anti-infectant, is not indicated, unless the client has an active
skin structure infection cause by MRSA or multidrug- resistant strains (MDRSP) of
Staphylococcus aureus. A sputum culture is not indicated9D) based on the client's history is
a wound infection.
205. A vacuum-assistive closure (VAC) device is being use to provide wound care for a
client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which
intervention should the nurse implement to ensure maximum effectiveness of the device?
Correct Ans ~ Ensure the transparent dressing has no tears that might create vacuum
leaks.
206. The nurse is developing the plan of care for a client with pneumonia and includes the
nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions."
Which intervention is most important for the nurse to include in the client's plan of care?
Correct Ans ~ Increase fluid intake to 3,000 ml/daily.
,207. The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test.
Which instruction should the nurse provide to the adult male client?
Correct Ans ~ Urinate at specific time, discard the urine, and collect all subsequent urine
during the next 24 hours.
Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine
during the next 24 hours is the correct procedure for collecting 24-hour urine specimen.
Discarding even one voided specimen invalidate the test.
208. The nurse is preparing to administer a histamine 2-receptor antagonist to a client with
peptic ulcer disease. What is the primary purpose of this drug classification?
Correct Ans ~ Decreases the amount of HCL secretion by the parietal cells in the stomach.
209. The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase
inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best
indicator of the drug's effectiveness? Correct Ans ~ Hemoglobin A1C (HbA1C) reading
less than 7%.
210. The nurse assesses a client with new onset diarrhea. It is most important for the nurse
to question the client about recent use of which type of medication?
Correct Ans ~ Antibiotics.
211. A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart
failure (HF). Which interventions should the nurse include in the infant's plan of care?
Correct Ans ~ Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%.
Evaluate heart rate for effectiveness of cardio tonic medications.
Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples.
Ensure Interrupted and frequent rest periods between procedures.
Rationale: Pulse oximetry screening supports prescribed level of O2. HR provides an
evaluative criterion for cardiac medications, which reduce heart rate, increase strength
contractions (inotropic effects) and consequently affect systemic circulation and tissue
oxygenation. Breast milk or basic formula provide 20 calories/ounce, so frequent feedings
with high energy formula. D minimize fatigue is necessary.
212. The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart
rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen
saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what
sequence, from first to last, should the nurse implement these actions? (Place the first
action on top and last action on the bottom.)
Correct Ans ~ 1. Start chest compressions with assisted manual ventilations.
2. Administer epinephrine 0.01 mg/kg intraosseous (IO).
3. Apply pads and prepare for transthoracic pacing.
4. Review the possible underlying causes for bradycardia.
213. An elderly male client is admitted to the mental health unit with a sudden onset of
global disorientation and is continuously conversing with his mother, who died 50 years
ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his
, urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that
his client is experiencing which condition?
Correct Ans ~ Delirium
214. Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult
to arouse, and his respiration are slow and shallow. Which action should the nurse
implement? Select all that apply.
Correct Ans ~ Prepare medication reversal agent.
Check oxygen saturation level.
Apply oxygen via nasal cannula.
Rationale: Sedation, given during the procedure may need to be reverse if the client does
not easily wake up. Oxygen saturation level should be asses, and oxygen applied to support
respiratory effort and oxygenation. The client is still breathing so the bag- valve mask
ventilation and CPR are not necessary.
215. The nurse is planning preoperative teaching plan of a 12-years old child who is
scheduled for surgery. To help reduce the child anxiety, which action is the best for the
nurse to implement?
Correct Ans ~ Provide a family tour of the preoperative unit one week before the surgery
is scheduled.
Rationale: School age children gain satisfaction from exploring and manipulating their
environment, thinking about objectives, situations and events, and making judgments
based on what they reason. A tour of the unit allows the child to see the hospital
environment and reinforce explanation and conceptual thinking.
216. Which intervention should the nurse implement during the administration of vesicant
chemotherapeutic agent via an IV site in the client's arm?
Correct Ans ~ Assess IV site frequently for signs of extravasation.
217. When development a teaching plan for a client newly diagnosed type 1 diabetes, the
nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA),
which action should the nurse instruct the client to implement if this sign of DKA occur?
Correct Ans ~ Give a dose of regular insulin per sliding scale.
Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client
manifest early signs of DKA that include excessive thirst, frequent urination, headache,
nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should
determine fingersticks glucose level and self-administer a dose of regular insulin per
sliding scale.
218. The nurse is teaching a group of clients with rheumatoid arthritis about the need to
modify daily activities. Which goal should the nurse emphasize?
Correct Ans ~ Protect joint function
219. An adult client experiences a gasoline tank fire when riding a motorcycle and is
admitted to the emergency department (ED) with full thickness burns to all surfaces of
201. A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4
days. Which finding indicates to the nurse that the medication is effective?
Correct Ans ~ Reduced level of pain.
202. A group of nurse-managers is asked to engage in a needs assessment for a piece of
equipment that will be expensed to the organization's budget. Which question is most
important to consider when analyzing the cost-benefit for this piece of equipment?
Correct Ans ~ How many departments can use this equipment?
203. While receiving a male postoperative client's staples de nurse observe that the client's
eyes are closed and his face and hands are clenched. The client states, "I just hate having
staples removed". After acknowledgement the client's anxiety, what action should the
nurse implement? Correct Ans ~ Attempt to distract the client with general conversation.
Rational: Distract is an effective strategy when a client experience anxiety during an
uncomfortable procedure. (A & D) increase the client's anxiety.
204. A male client is admitted for the removal of an internal fixation that was inserted for
the fracture ankle. During the admission history, he tells the nurse he recently received
vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound
infection. Which action should the nurse take? (Select all that apply.)
Correct Ans ~ Collect multiple site screening culture for MRSA.
Place the client on contact transmission precautions.
Continue to monitor for client sign of infection.
Rationale: Until multi-site screening cultures come back negative (A), the client should be
maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid
(Zyvox), a broad spectrum anti-infectant, is not indicated, unless the client has an active
skin structure infection cause by MRSA or multidrug- resistant strains (MDRSP) of
Staphylococcus aureus. A sputum culture is not indicated9D) based on the client's history is
a wound infection.
205. A vacuum-assistive closure (VAC) device is being use to provide wound care for a
client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which
intervention should the nurse implement to ensure maximum effectiveness of the device?
Correct Ans ~ Ensure the transparent dressing has no tears that might create vacuum
leaks.
206. The nurse is developing the plan of care for a client with pneumonia and includes the
nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions."
Which intervention is most important for the nurse to include in the client's plan of care?
Correct Ans ~ Increase fluid intake to 3,000 ml/daily.
,207. The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test.
Which instruction should the nurse provide to the adult male client?
Correct Ans ~ Urinate at specific time, discard the urine, and collect all subsequent urine
during the next 24 hours.
Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine
during the next 24 hours is the correct procedure for collecting 24-hour urine specimen.
Discarding even one voided specimen invalidate the test.
208. The nurse is preparing to administer a histamine 2-receptor antagonist to a client with
peptic ulcer disease. What is the primary purpose of this drug classification?
Correct Ans ~ Decreases the amount of HCL secretion by the parietal cells in the stomach.
209. The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase
inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best
indicator of the drug's effectiveness? Correct Ans ~ Hemoglobin A1C (HbA1C) reading
less than 7%.
210. The nurse assesses a client with new onset diarrhea. It is most important for the nurse
to question the client about recent use of which type of medication?
Correct Ans ~ Antibiotics.
211. A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart
failure (HF). Which interventions should the nurse include in the infant's plan of care?
Correct Ans ~ Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%.
Evaluate heart rate for effectiveness of cardio tonic medications.
Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples.
Ensure Interrupted and frequent rest periods between procedures.
Rationale: Pulse oximetry screening supports prescribed level of O2. HR provides an
evaluative criterion for cardiac medications, which reduce heart rate, increase strength
contractions (inotropic effects) and consequently affect systemic circulation and tissue
oxygenation. Breast milk or basic formula provide 20 calories/ounce, so frequent feedings
with high energy formula. D minimize fatigue is necessary.
212. The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart
rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen
saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what
sequence, from first to last, should the nurse implement these actions? (Place the first
action on top and last action on the bottom.)
Correct Ans ~ 1. Start chest compressions with assisted manual ventilations.
2. Administer epinephrine 0.01 mg/kg intraosseous (IO).
3. Apply pads and prepare for transthoracic pacing.
4. Review the possible underlying causes for bradycardia.
213. An elderly male client is admitted to the mental health unit with a sudden onset of
global disorientation and is continuously conversing with his mother, who died 50 years
ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his
, urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that
his client is experiencing which condition?
Correct Ans ~ Delirium
214. Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult
to arouse, and his respiration are slow and shallow. Which action should the nurse
implement? Select all that apply.
Correct Ans ~ Prepare medication reversal agent.
Check oxygen saturation level.
Apply oxygen via nasal cannula.
Rationale: Sedation, given during the procedure may need to be reverse if the client does
not easily wake up. Oxygen saturation level should be asses, and oxygen applied to support
respiratory effort and oxygenation. The client is still breathing so the bag- valve mask
ventilation and CPR are not necessary.
215. The nurse is planning preoperative teaching plan of a 12-years old child who is
scheduled for surgery. To help reduce the child anxiety, which action is the best for the
nurse to implement?
Correct Ans ~ Provide a family tour of the preoperative unit one week before the surgery
is scheduled.
Rationale: School age children gain satisfaction from exploring and manipulating their
environment, thinking about objectives, situations and events, and making judgments
based on what they reason. A tour of the unit allows the child to see the hospital
environment and reinforce explanation and conceptual thinking.
216. Which intervention should the nurse implement during the administration of vesicant
chemotherapeutic agent via an IV site in the client's arm?
Correct Ans ~ Assess IV site frequently for signs of extravasation.
217. When development a teaching plan for a client newly diagnosed type 1 diabetes, the
nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA),
which action should the nurse instruct the client to implement if this sign of DKA occur?
Correct Ans ~ Give a dose of regular insulin per sliding scale.
Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client
manifest early signs of DKA that include excessive thirst, frequent urination, headache,
nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should
determine fingersticks glucose level and self-administer a dose of regular insulin per
sliding scale.
218. The nurse is teaching a group of clients with rheumatoid arthritis about the need to
modify daily activities. Which goal should the nurse emphasize?
Correct Ans ~ Protect joint function
219. An adult client experiences a gasoline tank fire when riding a motorcycle and is
admitted to the emergency department (ED) with full thickness burns to all surfaces of
