EXIT HESI EXAM 2022/2023 (Answered) Verified
Solution
A nurse is reviewing the laboratory results of a client who has rheumatoid
arthritis. Which of the following findings should the nurse report to the provider?
a. WBC count 8,000
b. platelets 150,000
c. aspartate aminotransferase 10 units
d. erythrocyte sedimentation rate 75mm
d
A nurse is caring for a client who has generalized petechiae and ecchymoses.
The nurse should expect a prescription for which of the following laboratory
tests?
a. platelet count
b. potassium level
c. creatine clearance
d. prealbumin
a
A nurse is caring for a client following application of a cast. Which of the
following actions should the nurse take first?
a. place an ice pack over the cast
b. palpate the pulse distal to the cast
c. teach the client to keep the cast clean and dry
d. position the casted extremity on a pillow
b
A nurse is caring for a client who has vision loss. Which of the following actions
should the nurse take? SATA
a. keep objects in the clients room in the same place.
b. ensure there is high-wattage lighting in the clients room.
c. approach the client from the side
d. allow extra time for the client to perform tasks
e. touch the client gently to announce presence
a, b, d
A nurse is caring for a client who is newly diagnosed with pancreatic cancer and
has questions about the disease. To research the nurse should identify that
which of the following electronic database has the most comprehensive
collection nursing articles?
a. medline
b. C inahl
c. ProQuest
d. health source
b
A nurse in the emergency department is assessing newly admitted client who is
experiencing drooling and hoarseness following a brain injury. Which of the
following actions should the nurse take first?
a. obtain a baseline EKG
,b. Obtain a blood specimen for ABG analysis
c. insert an 18 gauge IV catheter
d. Administer 100% humidified oxygen
d
A nurse is planning care for a client who has unilateral paralysis and dysphagia
following a right hemispheric stroke. Which of the following interventions should
the nurse include in the plan?
a. Place food on the left side of the client's mouth when he is ready to eat.
b. Provide total care in performing the client's ADLs.
c. Maintain the client on bed rest.
d. Place the client's left arm on a pillow while he is sitting.
d
A nurse is caring for a client who is in a seclusion room following violent
behavior. The client continues to display aggressive behavior. Which of the
following actions should the nurse take?
a. Confront the client about this behavior.
b. Express sympathy for the client's situation.
c. Speak assertively to the client.
d. Stand within 30 cm (1 ft) of the client when speaking with them.
a
A nurse is caring for a client who is receiving brachytherapy for treatment of
prostate cancer. Which of the following actions should the nurse take?
a. Cleanse equipment before removal from the client's room.
b. Limit the client's visitors to 30 min per day.
c. Discard the client's linens in a double bag.
d. Discard the radioactive source in a biohazard bag
b
A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate
after the client displaces toxicity. Which of the following actions should the nurse
take?
a. Position the client supine
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
d. Administer calcium gluconate IV
d
A charge nurse is teaching new staff members about factors that increase a
client's risk to become violent. Which of the following risk factors should the
nurse include as the best predictor of future violence?
a. Experiencing delusions
b. Male gender
c. Pervious violent behavior
d. A history of being in prison
c
A nurse is preparing to perform a sterile dressing change. Which of the following
actions should the nurse take when setting up the sterile field?
,a. Place the cap from the solution sterile side up on clean surface
b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from
the body's first
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field →
2.5 cm (1-inch) border around any sterile drape or wrap that is considered
contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist
level; should be ABOVE waist level
a
A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instructions should the nurse include?
a. Eat a light snack before bedtime
c. Stay in bed at least 1 hr if unable to fall asleep
d. Take a 1 hr nap during the day
e. Perform exercises prior to bedtime
a
A home health nurse is preparing for an initial visit with an older adult client who
lives alone. Which of the following actions should the nurse take first?
a. Educate the client about current medical diagnosis
b. Refer the client to a meal delivery program
c. Identify environmental hazards in the home
d. Arrange for client transportation to follow-up appointments Rationale Priority:
Assess first.
c
A nurse is assessing the remote memory of an older adult client who has mild
dementia. Which of the following questions should the nurse ask the client?
a. "Can you tell me who visited you today?"
b. "What high school did you graduate from
c. "Can you list your current medications?"
d. "What did you have for breakfast yesterday?"
b
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus.
Which of the following goals should the nurse include in the teaching
a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. >
b. Blood glucose level greater than 200 mg/dL at bedtime
c. Blood glucose level less than 60 mg/dL before breakfast- < 70 =
HYPOGLYCEMIC
d. HbA1c level less than 7%
d
A nurse is caring for a client who is receiving phenytoin for management of grand
mal seizures and has a new prescription for isoniazid and rifampin. Which of the
following should the nurse conclude if the client develops ataxia and
incoordination?
a. The client is experiencing an adverse reaction to rifampin
b. The client's seizure disorder is no longer under control
, c. The client is showing evidence of phenytoin toxicity
d. The client is having adverse effects due to combination antimicrobial therapy
c
A nurse is caring for a client who is 1 hr postoperative following rhinoplasty.
Which of the following manifestations requires immediate action by the nurse?
a. Increase in frequency of swallowing→ may indicate bleeding
b. Moderate sanguineous drainage on the drip pad
c. Bruising to the face→ side effect
d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative)
a
Rationale "Requires immediate action" choose the worst possibility that could lead to.
ABC
A nurse is planning care for a preschool-age child who is in the acute phase
Kawasaki disease. Which of the following interventions should the nurse include
in the plan of care?
a. Give scheduled doses of acetaminophen every 6 hr
b. Monitor the child's cardiac status
c. Administer antibiotics via intermittent IV bolus for 24 hr
d. Provide stimulation with children of the same age in the playroom
b
A nurse is planning an educational program for high school students about
cigarette smoking. Which of the following potential consequences of smoking is
most likely to discourage adolescents from using tobacco?
a. Use of tobacco might lead to alcohol and drug abuse
b. Smoking in adolescence increases the risk of developing lung cancer later in
life
c. Use of tobacco decreases the level of athletic ability
d. Smoking in adolescence increases the risk of lifelong addiction
c
A nurse is assessing a client who is prescribed spironolactone. Which of the
following laboratory values should the nurse monitor for this client?
a. Total bilirubin
b. Urine ketones
c. Serum potassium- diuretic that retains potassium= hyperkalemic risk
d. Platelet count
c
A nurse has agreed to serve as an interpreter for an older adult client who is
assigned to another nurse. Which of the following statements by the nurse
indicates an understanding of this role?
a. "I will let the client know that I am available as the interpreter."
b. "I will receive a small fee for interpreting for this client."
c. "I am glad I'm available today, but when I'm not, you can use a family member."
d. "I will let the client know that an interpreter is unavailable during the night
shift."
a
Solution
A nurse is reviewing the laboratory results of a client who has rheumatoid
arthritis. Which of the following findings should the nurse report to the provider?
a. WBC count 8,000
b. platelets 150,000
c. aspartate aminotransferase 10 units
d. erythrocyte sedimentation rate 75mm
d
A nurse is caring for a client who has generalized petechiae and ecchymoses.
The nurse should expect a prescription for which of the following laboratory
tests?
a. platelet count
b. potassium level
c. creatine clearance
d. prealbumin
a
A nurse is caring for a client following application of a cast. Which of the
following actions should the nurse take first?
a. place an ice pack over the cast
b. palpate the pulse distal to the cast
c. teach the client to keep the cast clean and dry
d. position the casted extremity on a pillow
b
A nurse is caring for a client who has vision loss. Which of the following actions
should the nurse take? SATA
a. keep objects in the clients room in the same place.
b. ensure there is high-wattage lighting in the clients room.
c. approach the client from the side
d. allow extra time for the client to perform tasks
e. touch the client gently to announce presence
a, b, d
A nurse is caring for a client who is newly diagnosed with pancreatic cancer and
has questions about the disease. To research the nurse should identify that
which of the following electronic database has the most comprehensive
collection nursing articles?
a. medline
b. C inahl
c. ProQuest
d. health source
b
A nurse in the emergency department is assessing newly admitted client who is
experiencing drooling and hoarseness following a brain injury. Which of the
following actions should the nurse take first?
a. obtain a baseline EKG
,b. Obtain a blood specimen for ABG analysis
c. insert an 18 gauge IV catheter
d. Administer 100% humidified oxygen
d
A nurse is planning care for a client who has unilateral paralysis and dysphagia
following a right hemispheric stroke. Which of the following interventions should
the nurse include in the plan?
a. Place food on the left side of the client's mouth when he is ready to eat.
b. Provide total care in performing the client's ADLs.
c. Maintain the client on bed rest.
d. Place the client's left arm on a pillow while he is sitting.
d
A nurse is caring for a client who is in a seclusion room following violent
behavior. The client continues to display aggressive behavior. Which of the
following actions should the nurse take?
a. Confront the client about this behavior.
b. Express sympathy for the client's situation.
c. Speak assertively to the client.
d. Stand within 30 cm (1 ft) of the client when speaking with them.
a
A nurse is caring for a client who is receiving brachytherapy for treatment of
prostate cancer. Which of the following actions should the nurse take?
a. Cleanse equipment before removal from the client's room.
b. Limit the client's visitors to 30 min per day.
c. Discard the client's linens in a double bag.
d. Discard the radioactive source in a biohazard bag
b
A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate
after the client displaces toxicity. Which of the following actions should the nurse
take?
a. Position the client supine
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
d. Administer calcium gluconate IV
d
A charge nurse is teaching new staff members about factors that increase a
client's risk to become violent. Which of the following risk factors should the
nurse include as the best predictor of future violence?
a. Experiencing delusions
b. Male gender
c. Pervious violent behavior
d. A history of being in prison
c
A nurse is preparing to perform a sterile dressing change. Which of the following
actions should the nurse take when setting up the sterile field?
,a. Place the cap from the solution sterile side up on clean surface
b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from
the body's first
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field →
2.5 cm (1-inch) border around any sterile drape or wrap that is considered
contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist
level; should be ABOVE waist level
a
A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instructions should the nurse include?
a. Eat a light snack before bedtime
c. Stay in bed at least 1 hr if unable to fall asleep
d. Take a 1 hr nap during the day
e. Perform exercises prior to bedtime
a
A home health nurse is preparing for an initial visit with an older adult client who
lives alone. Which of the following actions should the nurse take first?
a. Educate the client about current medical diagnosis
b. Refer the client to a meal delivery program
c. Identify environmental hazards in the home
d. Arrange for client transportation to follow-up appointments Rationale Priority:
Assess first.
c
A nurse is assessing the remote memory of an older adult client who has mild
dementia. Which of the following questions should the nurse ask the client?
a. "Can you tell me who visited you today?"
b. "What high school did you graduate from
c. "Can you list your current medications?"
d. "What did you have for breakfast yesterday?"
b
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus.
Which of the following goals should the nurse include in the teaching
a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. >
b. Blood glucose level greater than 200 mg/dL at bedtime
c. Blood glucose level less than 60 mg/dL before breakfast- < 70 =
HYPOGLYCEMIC
d. HbA1c level less than 7%
d
A nurse is caring for a client who is receiving phenytoin for management of grand
mal seizures and has a new prescription for isoniazid and rifampin. Which of the
following should the nurse conclude if the client develops ataxia and
incoordination?
a. The client is experiencing an adverse reaction to rifampin
b. The client's seizure disorder is no longer under control
, c. The client is showing evidence of phenytoin toxicity
d. The client is having adverse effects due to combination antimicrobial therapy
c
A nurse is caring for a client who is 1 hr postoperative following rhinoplasty.
Which of the following manifestations requires immediate action by the nurse?
a. Increase in frequency of swallowing→ may indicate bleeding
b. Moderate sanguineous drainage on the drip pad
c. Bruising to the face→ side effect
d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative)
a
Rationale "Requires immediate action" choose the worst possibility that could lead to.
ABC
A nurse is planning care for a preschool-age child who is in the acute phase
Kawasaki disease. Which of the following interventions should the nurse include
in the plan of care?
a. Give scheduled doses of acetaminophen every 6 hr
b. Monitor the child's cardiac status
c. Administer antibiotics via intermittent IV bolus for 24 hr
d. Provide stimulation with children of the same age in the playroom
b
A nurse is planning an educational program for high school students about
cigarette smoking. Which of the following potential consequences of smoking is
most likely to discourage adolescents from using tobacco?
a. Use of tobacco might lead to alcohol and drug abuse
b. Smoking in adolescence increases the risk of developing lung cancer later in
life
c. Use of tobacco decreases the level of athletic ability
d. Smoking in adolescence increases the risk of lifelong addiction
c
A nurse is assessing a client who is prescribed spironolactone. Which of the
following laboratory values should the nurse monitor for this client?
a. Total bilirubin
b. Urine ketones
c. Serum potassium- diuretic that retains potassium= hyperkalemic risk
d. Platelet count
c
A nurse has agreed to serve as an interpreter for an older adult client who is
assigned to another nurse. Which of the following statements by the nurse
indicates an understanding of this role?
a. "I will let the client know that I am available as the interpreter."
b. "I will receive a small fee for interpreting for this client."
c. "I am glad I'm available today, but when I'm not, you can use a family member."
d. "I will let the client know that an interpreter is unavailable during the night
shift."
a
