ALL HESI EXIT Questions and Answers Test Bank; A+
Rated Guide (2022)
271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at
bedtime. What action should the nurse take? Correct Answer: Administer the
medication as prescribed with a glass of water
272. Which client should the nurse assess frequently because of the risk for
overflow incontinence? A client Correct Answer: Who is confused and frequently
forgets to go to the bathroom
273. While monitoring a client during a seizure, which interventions should the
nurse implement? (Select all that apply) Correct Answer: Move obstacle away
from client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure
274. A male client with a long history of alcoholism is admitted because of mild
confusion and fine motor tremors. He reports that he quit drinking alcohol and
stopped smoking cigarettes one month ago after his brother died of lung cancer.
Which intervention is most important for the nurses to include in the client's plan
of care? Correct Answer: Observe for changes in level of consciousness.
275. An older adult female admitted to the intensive care unit (ICU) with a
possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%,
and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results
after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To
normalize the client's ABG finding, which action is required? Correct Answer:
Increase ventilator rate.
276. The mother of the 12- month-old with cystic fibrosis reports that her child is
experiencing increasing congestion despite the use of chest physical therapy (CPT)
twice a day, and has also experiences a loss of appetite. What instruction should
the nurse provide? Correct Answer: CPT should be performed more frequently,
but at least an hour before meals.
277. The nurse is evaluating the diet teaching of a client with hypertension. What
dinner selection indicates that the client understands the dietary recommendation
,for hypertension? Correct Answer: Baked pork chop, applesauce, corn on the cob,
2% milk, and key-lime pie
278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic
episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units
subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h
are prescribed. What action should the nurse include in this client's plan of care?
Correct Answer: Fingerstick glucose assessment q6h with meals
Review with the client proper foot care and prevention of injury
Coordinate carbohydrate controlled meals at consistent times and intervals
Teach subcutaneous injection technique, site rotation and insulin management
279. Which problem reported by a client taking lovastatin requires the most
immediate fallow up by the nurse? Correct Answer: Muscle pain
280. While assessing a client's chest tube (CT), the nurse discovers bubbling in the
water seal chamber of the chest tube collection device. The client's vital signs are:
blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32
breaths/minutes, oxygen saturation 88%. Which interventions should the nurse
implement? Correct Answer: Provide supplemental oxygen
Auscultate bilateral lung fields
Reinforce occlusive CT dressing
281. 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?
Correct Answer: Ensure that the knot can be quickly released.
282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis
media. An antipyrine and benzocaine-otic also prescribed for pain and
inflammation. What instruction should the nurse emphasize concerning the
installation of the antipyrine/benzocaine otic solution? Correct Answer: Have the
child lie with the ear up for one to two minute after installation.
283. An older adult male is admitted with complications related to chronic
obstructive pulmonary disease (COPD). He reports progressive dyspnea that
worsens on exertion and his weakness has increased over the past month. The
nurse notes that he has dependent edema in both lower legs. Based on these
assessment findings, which dietary instruction should the nurse provide? Correct
Answer: Restrict daily fluid intake.
,284. The nurse inserts an indwelling urinary catheter as seen in the video what
action should the nurse take next? Correct Answer: Leave the catheter in place and
obtain a sterile catheter.
285. A client with coronary artery disease who is experiencing syncopal episodes
is admitted for an electrophysiology study (EPS) and possible cardiac ablation
therapy. Which intervention should the nurse delegate to the unlicensed assistive
personnel (UAP)? Correct Answer: Prepare the skin for procedure.
286. Fallowing an outbreak of measles involving 5 students in an elementary
school, which action is most important for the school nurse to take? Correct
Answer: Restrict unvaccinated children from attending school until measles
outbreak is resolved.
287. A preeclamptic client who delivered 24h ago remains in the labor and
delivery recovery room. She continues to receive magnesium sulfate at 2 grams per
hour. Her total input is limited to 125 ml per hour, and her urinary output for the
last hour was 850 ml. What intervention should the nurse implement? Correct
Answer: Continue with the plan of care for this client
288. The nurse is planning care for a client who admits having suicidal thoughts.
Which client behavior indicates the highest risk for the client acting on these
suicidal thoughts? Correct Answer: Begin to show signs of improvement in affect
289. When assessing a multigravida the first postpartum day, the nurse finds a
moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths
above the umbilicus. What action should the nurse implement first? Correct
Answer: Check for a destined bladder
290. A 12 year old client who had an appendectomy two days ago is receiving
0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What
action should the nurse implement? Correct Answer: Encourage popsicles and
fluids of choice
291. An older male client arrives at the clinic complaining that his bladder always
feels full. He complains of weak urine flow, frequent dribbling after voiding, and
increasing nocturia with difficulty initiating his urine stream. Which action should
the nurse implement? Correct Answer: Palpate the client's suprapubic area for
distention
, 292. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old
infant. Which action should the nurse include? Correct Answer: Divide the
medication into two injection with volumes under 1ml
293. A client who had a below the knee amputation is experiencing severe
phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain
stop. Which response by the nurse is likely to be most helpful? Correct Answer:
Research indicates that mirror therapy is effective in reducing phantom limb pain
294. An older adult client with heart failure (HF) develops cardiac tamponade. The
client has muffled, distant, heart sounds, and is anxious and restless. After
initiating oxygen therapy and IV hydration, which intervention is most important
for the nurse to implement? Correct Answer: Notify healthcare provider to prepare
for pericardiocentesis
295. A new member joins the nursing team spreads books on the table, puts items
on two chairs, and sits on a third chair. The members of the group are forced to
move closer and remove their possessions from the table what action should the
nurse leader take? Correct Answer: Ask the new person to move belonging to
accommodate others
296. The nurse is caring for a one week old infant who has a ventriculoperitoneal
(VP) shunt that was placed 2 days after birth. Which findings are an indication of a
postoperative complication? Correct Answer: Poor feeding and vomiting
Leakage of CSF from the incisional site
Abdominal distention
297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client who
weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml
multidose vial with the concentration of 1,000 USP units/ml. how many ml of
heparin should the nurse administer? (Enter numeric value only) Correct Answer:
8
298. In monitoring tissue perfusion in a client following an above the knee
amputation (aka), which action should the nurse include in the plan of care?
Correct Answer: Evaluate closet proximal pulse.
299. The leg of a client who is receiving hospice care have become mottled in
appearance. When the nurse observes the unlicensed assistive personal (UAP)
Rated Guide (2022)
271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at
bedtime. What action should the nurse take? Correct Answer: Administer the
medication as prescribed with a glass of water
272. Which client should the nurse assess frequently because of the risk for
overflow incontinence? A client Correct Answer: Who is confused and frequently
forgets to go to the bathroom
273. While monitoring a client during a seizure, which interventions should the
nurse implement? (Select all that apply) Correct Answer: Move obstacle away
from client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure
274. A male client with a long history of alcoholism is admitted because of mild
confusion and fine motor tremors. He reports that he quit drinking alcohol and
stopped smoking cigarettes one month ago after his brother died of lung cancer.
Which intervention is most important for the nurses to include in the client's plan
of care? Correct Answer: Observe for changes in level of consciousness.
275. An older adult female admitted to the intensive care unit (ICU) with a
possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%,
and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results
after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To
normalize the client's ABG finding, which action is required? Correct Answer:
Increase ventilator rate.
276. The mother of the 12- month-old with cystic fibrosis reports that her child is
experiencing increasing congestion despite the use of chest physical therapy (CPT)
twice a day, and has also experiences a loss of appetite. What instruction should
the nurse provide? Correct Answer: CPT should be performed more frequently,
but at least an hour before meals.
277. The nurse is evaluating the diet teaching of a client with hypertension. What
dinner selection indicates that the client understands the dietary recommendation
,for hypertension? Correct Answer: Baked pork chop, applesauce, corn on the cob,
2% milk, and key-lime pie
278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic
episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units
subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h
are prescribed. What action should the nurse include in this client's plan of care?
Correct Answer: Fingerstick glucose assessment q6h with meals
Review with the client proper foot care and prevention of injury
Coordinate carbohydrate controlled meals at consistent times and intervals
Teach subcutaneous injection technique, site rotation and insulin management
279. Which problem reported by a client taking lovastatin requires the most
immediate fallow up by the nurse? Correct Answer: Muscle pain
280. While assessing a client's chest tube (CT), the nurse discovers bubbling in the
water seal chamber of the chest tube collection device. The client's vital signs are:
blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32
breaths/minutes, oxygen saturation 88%. Which interventions should the nurse
implement? Correct Answer: Provide supplemental oxygen
Auscultate bilateral lung fields
Reinforce occlusive CT dressing
281. 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?
Correct Answer: Ensure that the knot can be quickly released.
282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis
media. An antipyrine and benzocaine-otic also prescribed for pain and
inflammation. What instruction should the nurse emphasize concerning the
installation of the antipyrine/benzocaine otic solution? Correct Answer: Have the
child lie with the ear up for one to two minute after installation.
283. An older adult male is admitted with complications related to chronic
obstructive pulmonary disease (COPD). He reports progressive dyspnea that
worsens on exertion and his weakness has increased over the past month. The
nurse notes that he has dependent edema in both lower legs. Based on these
assessment findings, which dietary instruction should the nurse provide? Correct
Answer: Restrict daily fluid intake.
,284. The nurse inserts an indwelling urinary catheter as seen in the video what
action should the nurse take next? Correct Answer: Leave the catheter in place and
obtain a sterile catheter.
285. A client with coronary artery disease who is experiencing syncopal episodes
is admitted for an electrophysiology study (EPS) and possible cardiac ablation
therapy. Which intervention should the nurse delegate to the unlicensed assistive
personnel (UAP)? Correct Answer: Prepare the skin for procedure.
286. Fallowing an outbreak of measles involving 5 students in an elementary
school, which action is most important for the school nurse to take? Correct
Answer: Restrict unvaccinated children from attending school until measles
outbreak is resolved.
287. A preeclamptic client who delivered 24h ago remains in the labor and
delivery recovery room. She continues to receive magnesium sulfate at 2 grams per
hour. Her total input is limited to 125 ml per hour, and her urinary output for the
last hour was 850 ml. What intervention should the nurse implement? Correct
Answer: Continue with the plan of care for this client
288. The nurse is planning care for a client who admits having suicidal thoughts.
Which client behavior indicates the highest risk for the client acting on these
suicidal thoughts? Correct Answer: Begin to show signs of improvement in affect
289. When assessing a multigravida the first postpartum day, the nurse finds a
moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths
above the umbilicus. What action should the nurse implement first? Correct
Answer: Check for a destined bladder
290. A 12 year old client who had an appendectomy two days ago is receiving
0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What
action should the nurse implement? Correct Answer: Encourage popsicles and
fluids of choice
291. An older male client arrives at the clinic complaining that his bladder always
feels full. He complains of weak urine flow, frequent dribbling after voiding, and
increasing nocturia with difficulty initiating his urine stream. Which action should
the nurse implement? Correct Answer: Palpate the client's suprapubic area for
distention
, 292. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old
infant. Which action should the nurse include? Correct Answer: Divide the
medication into two injection with volumes under 1ml
293. A client who had a below the knee amputation is experiencing severe
phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain
stop. Which response by the nurse is likely to be most helpful? Correct Answer:
Research indicates that mirror therapy is effective in reducing phantom limb pain
294. An older adult client with heart failure (HF) develops cardiac tamponade. The
client has muffled, distant, heart sounds, and is anxious and restless. After
initiating oxygen therapy and IV hydration, which intervention is most important
for the nurse to implement? Correct Answer: Notify healthcare provider to prepare
for pericardiocentesis
295. A new member joins the nursing team spreads books on the table, puts items
on two chairs, and sits on a third chair. The members of the group are forced to
move closer and remove their possessions from the table what action should the
nurse leader take? Correct Answer: Ask the new person to move belonging to
accommodate others
296. The nurse is caring for a one week old infant who has a ventriculoperitoneal
(VP) shunt that was placed 2 days after birth. Which findings are an indication of a
postoperative complication? Correct Answer: Poor feeding and vomiting
Leakage of CSF from the incisional site
Abdominal distention
297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client who
weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml
multidose vial with the concentration of 1,000 USP units/ml. how many ml of
heparin should the nurse administer? (Enter numeric value only) Correct Answer:
8
298. In monitoring tissue perfusion in a client following an above the knee
amputation (aka), which action should the nurse include in the plan of care?
Correct Answer: Evaluate closet proximal pulse.
299. The leg of a client who is receiving hospice care have become mottled in
appearance. When the nurse observes the unlicensed assistive personal (UAP)
