HESI RN Exit Exam Version 2
After receiving IV fluids in the emergency department, an elderly client is admitted
to the acute care unit with a medical diagnosis of dehydration. The client is
receiving 0.9% normal saline at 125 mL/hour via saline lock and has a bounding
pulse, tachycardia, and pedal edema. When contacting the healthcare provider, the
nurse anticipates a prescription what intervention?
A. Remove the saline lock from the client's arm
B. Increase the rate of the normal saline infusion
C. Decrease the rate of the normal saline infusion
D. Change the IV solution to 0.45% saline solution
(ANS- A. Remove the saline lock from the client's arm
A client who is admitted to the care unit with syndrome of inappropriate
antidiuretic hormone (SIADH) has developed osmotic demyelination. Which
intervention should the nurse implement first?
A. Patch one eye
B. Evaluate swallow
C. Reorient often
D. Range of motion
(ANS- B. Evaluate swallow
The nurse is preparing a client who had a below the knee (BKA) amputation for
discharge to home. Which recommendations should the nurse provide this client?
SATA
A. Wash the stump with soap and water
B. Avoid range of motion exercise
,C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
E. Use a residual limb shrinker
(ANS-
A. Wash the stump with soap and water
D. Inspect skin for redness
E. Use a residual limb shrinker
After 2 days treatment for dehydration, a child continues to vomit and have
diarrhea. Normal saline is infusing, and the child's urine output is 50 mL/hour.
During morning assessment, the nurse determines that the child is lethargic and
difficult to arouse. Which action should the nurse implement?
A. Perform a fingerstick glucose test.
B. Obtain arterial blood gases.
C. Increase the IV fluid flow rate.
D. Review 24 hour intake and output.
(ANS-
A. Perform a fingerstick glucose test.
Rationale:
A fingerstick glucose test (A) is indicated to determine if a change in level of
consciousness is related to a low glucose, which is a common finding with fluid
and electrolyte loss and can be quickly corrected. Arterial blood gases (B) may be
indicated to assess oxygenation, but first the glucose level should be assessed. The
child's urine output is adequate, so increasing the IV fluid rate (C) is not indicated.
Knowing the last 24 hour fluid volume totals (D) does not address the immediate
problem.
,A client with bleeding esophageal varices receives vasopressin IV. What should
the nurse monitor for during the IV infusion of this medication?
A. Vasodilatation of the extremities
B. Chest pain and dysrhythmia
C. Hypotension and tachycardia
D. decreasing GI cramping and nausea
(ANS- B. Chest pain and dysrhythmia
A male client with an antisocial personality disorder is admitted to an inpatient
mental health unit for multiple substance dependency. When providing a history,
the client justifies to the nurse his use of illicit drugs. Based on this pattern of
behavior, this client's history is most likely to include which finding?
A. Multiple convictions of misdemeanors and Class B felonies
B. Delusions of grandiosity and persecution
C. Suicidal ideations and multiple attempts
D. Photos and panic attacks when confronted by authority figures
(ANS- A. Multiple convictions of misdemeanors and Class B felonies
An older client is admitted for repair of a broken hip. To reduce the risk for
infection postoperative period, which nursing care intervention should the nurse
include the client's plan of care? Select all that apply
A. administer low molecular weight heparin as prescribed
B. Teach client to use incentive spirometer every 2 hours while awake
C. Remove urinary catheter as soon as possible and encourage voiding
D. Maintain sequential compression devices while in bed
E. Assess pain level and medicate PRN as prescribed
, (ANS-
B. Teach client to use incentive spirometer every 2 hours while awake
C. Remove urinary catheter as soon as possible and encourage voiding
The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin
shock. How should the nurse administer the medication?
A. Dilute the dextrose in one liter of 0.9% Normal Saline solution
B. Push undiluted slowly through the currently infusing IV
C. Mix the dextrose in a 50 mL piggyback for a total volume of 100 mL
D. Ask the pharmacist to add the Dextrose to a TPN solution.
(ANS- B. Push undiluted slowly through the currently infusing IV
A client with arthritis has been receiving treatment with naproxen and now reports
ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test
should the nurse monitor?
A. Serum calcium
B. Erythrocyte sedimentation rate
C. Osmolality
D. Hemoglobin
(ANS- D. Hemoglobin
A client with bacterial meningitis is receiving phenytoin. Which assessment
finding indication to the nurse that the client is experiencing a therapeutic response
to the phenytoin?
A. increased time of ambulation between periods of rest
B. Decrease in intracranial pressure and cerebral edema
C. Absence of seizure activity for the duration of treatment
After receiving IV fluids in the emergency department, an elderly client is admitted
to the acute care unit with a medical diagnosis of dehydration. The client is
receiving 0.9% normal saline at 125 mL/hour via saline lock and has a bounding
pulse, tachycardia, and pedal edema. When contacting the healthcare provider, the
nurse anticipates a prescription what intervention?
A. Remove the saline lock from the client's arm
B. Increase the rate of the normal saline infusion
C. Decrease the rate of the normal saline infusion
D. Change the IV solution to 0.45% saline solution
(ANS- A. Remove the saline lock from the client's arm
A client who is admitted to the care unit with syndrome of inappropriate
antidiuretic hormone (SIADH) has developed osmotic demyelination. Which
intervention should the nurse implement first?
A. Patch one eye
B. Evaluate swallow
C. Reorient often
D. Range of motion
(ANS- B. Evaluate swallow
The nurse is preparing a client who had a below the knee (BKA) amputation for
discharge to home. Which recommendations should the nurse provide this client?
SATA
A. Wash the stump with soap and water
B. Avoid range of motion exercise
,C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
E. Use a residual limb shrinker
(ANS-
A. Wash the stump with soap and water
D. Inspect skin for redness
E. Use a residual limb shrinker
After 2 days treatment for dehydration, a child continues to vomit and have
diarrhea. Normal saline is infusing, and the child's urine output is 50 mL/hour.
During morning assessment, the nurse determines that the child is lethargic and
difficult to arouse. Which action should the nurse implement?
A. Perform a fingerstick glucose test.
B. Obtain arterial blood gases.
C. Increase the IV fluid flow rate.
D. Review 24 hour intake and output.
(ANS-
A. Perform a fingerstick glucose test.
Rationale:
A fingerstick glucose test (A) is indicated to determine if a change in level of
consciousness is related to a low glucose, which is a common finding with fluid
and electrolyte loss and can be quickly corrected. Arterial blood gases (B) may be
indicated to assess oxygenation, but first the glucose level should be assessed. The
child's urine output is adequate, so increasing the IV fluid rate (C) is not indicated.
Knowing the last 24 hour fluid volume totals (D) does not address the immediate
problem.
,A client with bleeding esophageal varices receives vasopressin IV. What should
the nurse monitor for during the IV infusion of this medication?
A. Vasodilatation of the extremities
B. Chest pain and dysrhythmia
C. Hypotension and tachycardia
D. decreasing GI cramping and nausea
(ANS- B. Chest pain and dysrhythmia
A male client with an antisocial personality disorder is admitted to an inpatient
mental health unit for multiple substance dependency. When providing a history,
the client justifies to the nurse his use of illicit drugs. Based on this pattern of
behavior, this client's history is most likely to include which finding?
A. Multiple convictions of misdemeanors and Class B felonies
B. Delusions of grandiosity and persecution
C. Suicidal ideations and multiple attempts
D. Photos and panic attacks when confronted by authority figures
(ANS- A. Multiple convictions of misdemeanors and Class B felonies
An older client is admitted for repair of a broken hip. To reduce the risk for
infection postoperative period, which nursing care intervention should the nurse
include the client's plan of care? Select all that apply
A. administer low molecular weight heparin as prescribed
B. Teach client to use incentive spirometer every 2 hours while awake
C. Remove urinary catheter as soon as possible and encourage voiding
D. Maintain sequential compression devices while in bed
E. Assess pain level and medicate PRN as prescribed
, (ANS-
B. Teach client to use incentive spirometer every 2 hours while awake
C. Remove urinary catheter as soon as possible and encourage voiding
The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin
shock. How should the nurse administer the medication?
A. Dilute the dextrose in one liter of 0.9% Normal Saline solution
B. Push undiluted slowly through the currently infusing IV
C. Mix the dextrose in a 50 mL piggyback for a total volume of 100 mL
D. Ask the pharmacist to add the Dextrose to a TPN solution.
(ANS- B. Push undiluted slowly through the currently infusing IV
A client with arthritis has been receiving treatment with naproxen and now reports
ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test
should the nurse monitor?
A. Serum calcium
B. Erythrocyte sedimentation rate
C. Osmolality
D. Hemoglobin
(ANS- D. Hemoglobin
A client with bacterial meningitis is receiving phenytoin. Which assessment
finding indication to the nurse that the client is experiencing a therapeutic response
to the phenytoin?
A. increased time of ambulation between periods of rest
B. Decrease in intracranial pressure and cerebral edema
C. Absence of seizure activity for the duration of treatment
