HESI RN EXIT EXAM V5 2022 ACTUAL EXAM
HESI RN EXIT EXAM V5 2022 ACTUAL EXAM
After placing a 36- week- gestation newborn in an isolette and drying the infant with several blankets,
what should the nurse implement next? - ANS Remove the wet blankets and linen from the isolette
A client in the third trimester of pregnancy complains of frequent nasal stiffness and occasional
nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic
breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should
the nurse implement? - ANS Record the respiratory finding in the clients chart as normal
A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings.
His appetite is poor and he often refuses oral intake of solids and liquids. For the past several days he
has been unable to get out of bed. Which action should the hospice nurse implement? - ANS Instruct
family to offer client only soft bland foods
A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy test and
ultrasound were negative, so an exploratory laparotomy was completed during the night. When coffee
ground materials is observed in the drainage from the nasogastric tube (NGT), which intervention should
the nurse implement? - ANS Verify correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports of the
abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to
evaluate the clients clinical recovery? - ANS Lipase
While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL of dark
red fluid has drained from the nasogastric tube in the last hour. Which action should the nurse take
first? - ANS take vital signs
The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis,
and emphysema. Which health care measure is most important for the nurse to recommend to these
clients? - ANS Avoid large crowded areas during the colder months of the year
The mother of a one-moth-old infant calls the clinic to report that the back of her infant's head is flat.
How should the nurse respond? - ANS Position the infant on the stomach occasionally when awake and
active
A woman is brought to the labor and delivery unti after delivering a term infant and the placenta in the
hospital parking lot 10 minutes ago. Which action should the nurse perform first? - ANS Perform a
fundal massage
A client has a new prescription for the maximum recommended dosage of pipercillin/tazobactam for
nosocomial pneumonia. The nurse should report which laboratory finding to the healthcare provider
before administering the prescribed dose? - ANS Decrease serum creatine
,HESI RN EXIT EXAM V5 2022 ACTUAL EXAM
A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing and has a
severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg;
HCO3 24 mEq/L (24mmol/L). Which assessment finding warrants immediate intervention by the nurse? -
ANS Fruity breath
When performing postural drainage on a client with Chronic Obstructive Pulmonary disease (COPD),
which approach should the nurse use? - ANS Explain that the client may be placed in five positions
A young male client with testicular cancer has a living will that describes his desire that no extraordinary
measures be taken to save his life. The healthcare provider knows the client has a good prognosis and
refuses to write a "do not resuscitate" (DNR) prescription. Which action should the nurse take? - ANS
Initiate an ethics committee review
In observing a clients face, which assessment finding requires the most immediate intervention by the
nurse? - ANS Oral mucosa is cyanotic Blue lips
The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex.
Which action should the nurse take in response to the finding? - ANS Complete a thorough neurological
assessment
Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from
an indwelling urinary catheter? - ANS Ensure continued sterility of the specimen container
The home health nurse observes an older client with unilateral weakness place the walker in front of the
chair for support while rising to a standing position. Which action should the nurse take? - ANS Hold the
chair
A client with cancer complains of fever, chills, malaise, and headache following administration of a
colony-stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu like
symptoms? - ANS Monitor lab values for an increase in WBCs
Which laboratory value should the nurse review prior to administering the initial dose of a statin
medication? - ANS Serum liver enzymes
Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that
the client is experiencing a complication of the procedure? - ANS I have a headache that gets worse
when I sit up
The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a
prescription for clonidine 0.2 mg PO taken twice daily. Which action should the nurse take? - ANS Advise
to sit up slowly from a reclining position
A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a
health history form the child's mother, the recent occurrence of what illness is most significant? - ANS
Sore throat
, HESI RN EXIT EXAM V5 2022 ACTUAL EXAM
Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy
products, such as milk, to help coat and protect their ulcer. Which is the best follow-up action by the
nurse? - ANS Review with the client the need to avoid foods that are rich in milk and cream
The nurse assesses a client with cirrhosis and find 4+ pitting edema of the feet and legs, and massive
ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? - ANS
hyperaldosteronism caused by decreased degradation of the hormone by the liver.
The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe,
colicky abdominal pain, nauseas, vomiting, and abdominal distention. Which pathophysiological
mechanism supports the client's clinical presentation? - ANS A weakened diaphragm with high
abdominal pressure
An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a
tunnel." The client expresses great concern about going blind. Which nursing instruction is most
important for the nurse to provide to this client? - ANS Maintain prescribed eye drop regimen
The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new
graduate who is orienting to the unit? - ANS A new graduate should be able to complete a pre-
procedural checklist and get this client to the catheterization lab.
Penicillin G procaine 240,000 units intramuscularly is prescribed for a 4-year-old child who has
streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2mL. How many mL
should the nurse administer? - ANS 0.4 D/HX2ml
A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the
perineum. What action should the nurse perform first? - ANS knee chest position
A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While
taking the blood pressure, the client begins to demonstrate cloudy consciousness, stupor, and has
slurred speech. The nurse obtains blood glucose of 50 mg/dL, heart rate of 116 beats/minute, and blood
pressure of 88/50 mmHg. Which intervention is most important for the nurse to implement? - ANS
Position client with head flat and feet elevated
The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA)> the nurse
includes activities to strengthen and mobilize the joints surrounding muscle. Which physical therapy
regimen should the nurse encourage the adolescent to implement? - ANS Exercise in the swimming pool
The nurse is educating a client with end-stage kidney failure who requires dialysis three times a week.
Which information is important for the nurse to include about the clients daily diet? - ANS The protein
intake should be decreased to prevent nitrogenous waste Buildup
A client is admitted to the hospital with symptoms consistent with a right hemispheric stroke. Which
neurovascular assessment requires immediate intervention by the nurse? - ANS Unequal bilateral hand
grip strengths
HESI RN EXIT EXAM V5 2022 ACTUAL EXAM
After placing a 36- week- gestation newborn in an isolette and drying the infant with several blankets,
what should the nurse implement next? - ANS Remove the wet blankets and linen from the isolette
A client in the third trimester of pregnancy complains of frequent nasal stiffness and occasional
nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic
breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should
the nurse implement? - ANS Record the respiratory finding in the clients chart as normal
A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings.
His appetite is poor and he often refuses oral intake of solids and liquids. For the past several days he
has been unable to get out of bed. Which action should the hospice nurse implement? - ANS Instruct
family to offer client only soft bland foods
A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy test and
ultrasound were negative, so an exploratory laparotomy was completed during the night. When coffee
ground materials is observed in the drainage from the nasogastric tube (NGT), which intervention should
the nurse implement? - ANS Verify correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports of the
abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to
evaluate the clients clinical recovery? - ANS Lipase
While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL of dark
red fluid has drained from the nasogastric tube in the last hour. Which action should the nurse take
first? - ANS take vital signs
The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis,
and emphysema. Which health care measure is most important for the nurse to recommend to these
clients? - ANS Avoid large crowded areas during the colder months of the year
The mother of a one-moth-old infant calls the clinic to report that the back of her infant's head is flat.
How should the nurse respond? - ANS Position the infant on the stomach occasionally when awake and
active
A woman is brought to the labor and delivery unti after delivering a term infant and the placenta in the
hospital parking lot 10 minutes ago. Which action should the nurse perform first? - ANS Perform a
fundal massage
A client has a new prescription for the maximum recommended dosage of pipercillin/tazobactam for
nosocomial pneumonia. The nurse should report which laboratory finding to the healthcare provider
before administering the prescribed dose? - ANS Decrease serum creatine
,HESI RN EXIT EXAM V5 2022 ACTUAL EXAM
A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing and has a
severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg;
HCO3 24 mEq/L (24mmol/L). Which assessment finding warrants immediate intervention by the nurse? -
ANS Fruity breath
When performing postural drainage on a client with Chronic Obstructive Pulmonary disease (COPD),
which approach should the nurse use? - ANS Explain that the client may be placed in five positions
A young male client with testicular cancer has a living will that describes his desire that no extraordinary
measures be taken to save his life. The healthcare provider knows the client has a good prognosis and
refuses to write a "do not resuscitate" (DNR) prescription. Which action should the nurse take? - ANS
Initiate an ethics committee review
In observing a clients face, which assessment finding requires the most immediate intervention by the
nurse? - ANS Oral mucosa is cyanotic Blue lips
The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex.
Which action should the nurse take in response to the finding? - ANS Complete a thorough neurological
assessment
Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from
an indwelling urinary catheter? - ANS Ensure continued sterility of the specimen container
The home health nurse observes an older client with unilateral weakness place the walker in front of the
chair for support while rising to a standing position. Which action should the nurse take? - ANS Hold the
chair
A client with cancer complains of fever, chills, malaise, and headache following administration of a
colony-stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu like
symptoms? - ANS Monitor lab values for an increase in WBCs
Which laboratory value should the nurse review prior to administering the initial dose of a statin
medication? - ANS Serum liver enzymes
Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that
the client is experiencing a complication of the procedure? - ANS I have a headache that gets worse
when I sit up
The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a
prescription for clonidine 0.2 mg PO taken twice daily. Which action should the nurse take? - ANS Advise
to sit up slowly from a reclining position
A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a
health history form the child's mother, the recent occurrence of what illness is most significant? - ANS
Sore throat
, HESI RN EXIT EXAM V5 2022 ACTUAL EXAM
Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy
products, such as milk, to help coat and protect their ulcer. Which is the best follow-up action by the
nurse? - ANS Review with the client the need to avoid foods that are rich in milk and cream
The nurse assesses a client with cirrhosis and find 4+ pitting edema of the feet and legs, and massive
ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? - ANS
hyperaldosteronism caused by decreased degradation of the hormone by the liver.
The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe,
colicky abdominal pain, nauseas, vomiting, and abdominal distention. Which pathophysiological
mechanism supports the client's clinical presentation? - ANS A weakened diaphragm with high
abdominal pressure
An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a
tunnel." The client expresses great concern about going blind. Which nursing instruction is most
important for the nurse to provide to this client? - ANS Maintain prescribed eye drop regimen
The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new
graduate who is orienting to the unit? - ANS A new graduate should be able to complete a pre-
procedural checklist and get this client to the catheterization lab.
Penicillin G procaine 240,000 units intramuscularly is prescribed for a 4-year-old child who has
streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2mL. How many mL
should the nurse administer? - ANS 0.4 D/HX2ml
A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the
perineum. What action should the nurse perform first? - ANS knee chest position
A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While
taking the blood pressure, the client begins to demonstrate cloudy consciousness, stupor, and has
slurred speech. The nurse obtains blood glucose of 50 mg/dL, heart rate of 116 beats/minute, and blood
pressure of 88/50 mmHg. Which intervention is most important for the nurse to implement? - ANS
Position client with head flat and feet elevated
The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA)> the nurse
includes activities to strengthen and mobilize the joints surrounding muscle. Which physical therapy
regimen should the nurse encourage the adolescent to implement? - ANS Exercise in the swimming pool
The nurse is educating a client with end-stage kidney failure who requires dialysis three times a week.
Which information is important for the nurse to include about the clients daily diet? - ANS The protein
intake should be decreased to prevent nitrogenous waste Buildup
A client is admitted to the hospital with symptoms consistent with a right hemispheric stroke. Which
neurovascular assessment requires immediate intervention by the nurse? - ANS Unequal bilateral hand
grip strengths
