HESI RN EXIT EXAM NEW FILE 150 Questions & Answers

1. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? "In some instancesthe resultis a retarded bone growth." 2. A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? Monitor vital signs 3. A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse? Listen quietly without comment 4. The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's immediate attention? "I am itching all over." 5. A depressed client is experiencing severe insomnia. The health care provider orders trazadone (Desyrel). The nurse tells the client to expect? Relief of insomnia 6. The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse's immediate attention? Blood glucose of 350 mg/dl 7. Which of the following classifications of medications would be most often used for clients with schizophrenia? Neuroleptics 8. The nurse is teaching administration of albuterol inhalation to an adult with asthma. Which of the following demonstrates proper teaching? "Notify the health care provider if you need the drug more often." 9. The nurse is caring for a client with Parkinson's disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor? L-Dopa 10. The nurse is administering albuterol (Proventil) to a child with asthma. Which of the following assessments by the nurse indicate the need for an adjustment of the medication? Apical Pulse of 112 11. A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse’s contribution and begins to find objections to the suggestion. The nurse manager's best response is to Let’s move to the ‘what if…’ as related to these objections for an exploration of spin off ideas. 12. When teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that which of these is the most common side effect? Headache 13. The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? Determine if the home health aide's care is consistent with the plan of care 14. An RN from the women’s health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse? A client from a motor vehicle accident with an external fixation device on the leg 15. A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which o staff members should the charge nurse assign the client? RN 16. A charge nurse working in a long term care facility is making out assignments. Which assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires intervention by the supervisor? Teaching a family intermittent (bolus) feedings via G-tube before discharge 17. Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP? Provide basic hygiene care to all clients on the unit 18. The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? Unlicensed assistive personnel (UAP) 19. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention? Decrease in chest wall expansion 20. The charge nurse on a cardiac step-down unit makes assignments for the team consisting of an RN, a PN, and an unlicensed assistive person. Which client should be assigned to the PN? A 58 year-old hypertensive with possible angina 21. A client experiences intense anxiety after the home was destroyed by a fire. The client escaped from the fire with only minor injuries. The nurse knows that the most important initial intervention would be to: Determine available community and personal resources 22. The client referred for a mammography questions the nurses about the cancer risks from radiation exposure. What is the appropriate response by the nurse? The radiation from a mammography is equivalent to 1 hour of sun exposure 23. The client with multiple sclerosis has an order to change the nasogastric tube. To promote safety when removing the tube, the nurse should: ask the client to hold a breath 24. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? Risk for infection 25. A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are complaining. As a change agent, the nurse manager should first: Explore how the planning committee evaluated barriers to the plan 26. A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action? Report this immediately to the nurse manager 27. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate? Administer the medication with a syringe next to the tongue 28. During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client's knees. The best action for the nurse to take is to: Ask the client for more information about the nature of the bruises 29. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age? Separation anxiety 30. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age? Death is personified as the bogeyman or devil 31. Which statement describes the use of a decision grid for decision making? It is both a visual and a quantitative method of decision making 32. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition? Drug tolerance 33. The nurse is speaking to a group of parents and school teachers of children about care for children with rheumatic fever. It is a priority to emphasize that: Clumsiness and behavior changes should be reported 34. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention? Respiratory rate of 32 35. The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's Syndrome? Varicella 36. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis? The infant received mechanical ventilation for 2 weeks 37. Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child? My child doesn't like many fruits and vegetables, but she really loves her milk 38. The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize The importance of walking as much as possible 39. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to: go get a blood pressure check within the next 48 to 72 hours 40. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? Mild vomiting that progressed to vomiting shooting across the room 41. The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspect of this care is: Humidified air and increased oral fluids 42. A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process? Disruption of fetal glucose supply 43. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching? I dip his pacifier in honey so he'll take it 44. Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy? Succinylcholine (Anectine) 45. To prevent drug resistance common to tubercle bacilli, the nurse is aware that which of the following agents are usually added to drug therapy? Two anti-tuberculosis drugs 46. The charge nurse reviews the charting of a graduate nurse. Which indicates a need for further education on documentation? Charts some actions in advance of performing them 47. The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? Sodium level, 125 mEq/L 48. The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first? A women at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn 49. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? Excessive CNS stimulation will be reduced. 50. A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? Spontaneous bruising 51. A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's: Physical and functional abilities 52. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal: S3 ventricular gallop 53. An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? Check the client’s gag reflex 54. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A myocardial infarction that is free from pain and dysrhythmias 55. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4year-old child? "I have the 4 year-old hold and help feed the four month-old a bottle inthe kitchen while I make supper." 56. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? Pain related to ischemia 57. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first? Potassium levels 58. The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching? "The therapy can be discontinued when the spots disappear." 59. The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP? Monitor the client's response to ambulatory activity 60. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behavior is a warning sign to indicate that the client may be: headed for relapse 61. The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include: Consistent limit-setting enforced 24 hours per day 62. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first? Encourage her to talk about her view of herself 63. A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present? An open wound on their heel 64. A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child? Eating peanuts 65. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? "When you can climb 2 flights of stairs without problems, it is generally safe." 66. A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct? Days 17-19 67. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering: Vena caval interruption 68. While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age? 2 years of age 69. While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best? "Is there a reason why you don't want to take your medicine?" 70. A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not want it." The nurse's best response is: ‘You seem upset; tell me what the pregnancy and birth were like for you’ 71. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time? What does the skin on the testicles look and feel like? 72. The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children? Epiphyseal fractures often interrupt a child's normal growth pattern 73. The nurse is planning to administer otic drops to a 6 year-old child. Which of the following is the correct procedure? Hold the pinna up and back to instill the drops 74. The nurse is assessing a client who has taken haldol (Haloperidol) for several months. Which of the following is a side effect of this medication and must be reported immediately to the health care provider? Dystonic reaction 75. A client admits to benzodiazepine dependence for several years. She is now in a