Hesi Exit Exam
1. A client is receiving a continuous half strength tube feeding at
50ml/hour. To prepare enough of the solution for eight hours, how many ml
of full strength feeding will the nurse need? (Enter numeric value only.):
200ml . 25 ml of full strength feeding mixed with 25ml of water
provided 50ml of half strength. 25ml × 8 hours= 200ml
2. An elderly male client is experiencing urinary incontinence. What is
the best initial nursing action?: Apply an external condom catheter
3. 3. A male Muslim client with pneumonia is scheduled to receive a dose
of an intravenous antibiotic but refuses to allow the nurse to begin the
medication, stating he cannot allow fluids to enter his body once he is
cleansed for prayer. What action should the nurse implement?:
Reschedule administration of the antibiotic until after he completes
his prayers
4. UAP using a hand sanitzers that is alcohol for 2 minutes: tell that
hand sanitizer use is less > 2min
5. 5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour
before a scheduled procedure. The child weighs 44 pounds. How many mg
of the medication should the nurse administer: Answer: 800 Rationale:
First, convert the child's weight to kg: 44 pounds divided by
2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg =
800mg
6. 6. While assisting a postpartum client with perineal care, the nurse notes
that her vaginal bleeding spurts rather than trickles from the vagina. The
uterine fundus is firm and the client's vital signs are pulse 88 beats/minute;
respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg.
What action should the nurse take next?: Compare current vital signs
with previous vital signs
7. A 6-year old boy was hit with a bat while playing at school. He has a
splinter of wood imbedded in his eye. Which action should the school
nurse take?: Have the parent take the child for emergency help
8. Within four weeks of childbirth, a client is admitted to the hospital for
disorganized speech bizarre behavior, and strange thoughts about her in-
fant being possessed by demons. The nurse identifies a nursing
diagnosis of "Altered thought processes, secondary to" what condition?:
Postpartum psychosis
,9. The nurse identifies a priority diagnosis of, "Altered comfort related
to menstrual cramps" for a 25-year-old female client. Which self-care
activity
, should the nurse emphasize in the client's teaching plan?: Regular
aerobic exercise.
10.Psych/Alcohol/Tylenol overdose antidote: Give Mucomyst
11.Medical Surgical/Laxative abuses: Patient -taking Milk of Magnesium
12.Spiritual/Documentation: Native American - Allow pt's family to
stay in the room
13.Leadership- Interpreter informed consent: Pt should sign the consent
14.Geriatrics/Emergency Rib fractures fall: Pulmonary embolism
15.A client diagnosed with major depression is being allowed a weekend
pass from the psychiatric unit. Which instruction should the nurse
provide to the client's family?: Involve the client in usual at home
activities
16. Upon assessment, the nurse discovers that a postpartum client
has persistent red lochia.
Which of the following does this assessment finding suggest to the nurse?-
: Coagulation disorders
17.The healthcare provider performs peritoneal dialysis on a client,
after which 2 liters of fluid is drained. What action should the nurse
complete first?: Assess vital signs.
18.After administering a medication through a nasogastric tube
connected to suction, what action should the nurse take first?: Clamp the
tube
19. The nurse is caring for four clients: Client A 94% o2 saturation, Client
B, hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a
white blood cell count of 15,000. What
should the nurse implement?: Determine if Client B has two units of
packed cells available in the blood bank.
20.Triage question with a train wreck The psychiatric nurse is called to a
train derailment that was likely caused by a terrorist bomb. In triaging
those in need of immediate care, what is the priority ranking for these
cases? (arrange these cases in order or priority with the top item requiring
the most immediate care and the bottom item requiring the least priority
care): A mother and father have just arrived on the .
1. A client is receiving a continuous half strength tube feeding at
50ml/hour. To prepare enough of the solution for eight hours, how many ml
of full strength feeding will the nurse need? (Enter numeric value only.):
200ml . 25 ml of full strength feeding mixed with 25ml of water
provided 50ml of half strength. 25ml × 8 hours= 200ml
2. An elderly male client is experiencing urinary incontinence. What is
the best initial nursing action?: Apply an external condom catheter
3. 3. A male Muslim client with pneumonia is scheduled to receive a dose
of an intravenous antibiotic but refuses to allow the nurse to begin the
medication, stating he cannot allow fluids to enter his body once he is
cleansed for prayer. What action should the nurse implement?:
Reschedule administration of the antibiotic until after he completes
his prayers
4. UAP using a hand sanitzers that is alcohol for 2 minutes: tell that
hand sanitizer use is less > 2min
5. 5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour
before a scheduled procedure. The child weighs 44 pounds. How many mg
of the medication should the nurse administer: Answer: 800 Rationale:
First, convert the child's weight to kg: 44 pounds divided by
2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg =
800mg
6. 6. While assisting a postpartum client with perineal care, the nurse notes
that her vaginal bleeding spurts rather than trickles from the vagina. The
uterine fundus is firm and the client's vital signs are pulse 88 beats/minute;
respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg.
What action should the nurse take next?: Compare current vital signs
with previous vital signs
7. A 6-year old boy was hit with a bat while playing at school. He has a
splinter of wood imbedded in his eye. Which action should the school
nurse take?: Have the parent take the child for emergency help
8. Within four weeks of childbirth, a client is admitted to the hospital for
disorganized speech bizarre behavior, and strange thoughts about her in-
fant being possessed by demons. The nurse identifies a nursing
diagnosis of "Altered thought processes, secondary to" what condition?:
Postpartum psychosis
,9. The nurse identifies a priority diagnosis of, "Altered comfort related
to menstrual cramps" for a 25-year-old female client. Which self-care
activity
, should the nurse emphasize in the client's teaching plan?: Regular
aerobic exercise.
10.Psych/Alcohol/Tylenol overdose antidote: Give Mucomyst
11.Medical Surgical/Laxative abuses: Patient -taking Milk of Magnesium
12.Spiritual/Documentation: Native American - Allow pt's family to
stay in the room
13.Leadership- Interpreter informed consent: Pt should sign the consent
14.Geriatrics/Emergency Rib fractures fall: Pulmonary embolism
15.A client diagnosed with major depression is being allowed a weekend
pass from the psychiatric unit. Which instruction should the nurse
provide to the client's family?: Involve the client in usual at home
activities
16. Upon assessment, the nurse discovers that a postpartum client
has persistent red lochia.
Which of the following does this assessment finding suggest to the nurse?-
: Coagulation disorders
17.The healthcare provider performs peritoneal dialysis on a client,
after which 2 liters of fluid is drained. What action should the nurse
complete first?: Assess vital signs.
18.After administering a medication through a nasogastric tube
connected to suction, what action should the nurse take first?: Clamp the
tube
19. The nurse is caring for four clients: Client A 94% o2 saturation, Client
B, hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a
white blood cell count of 15,000. What
should the nurse implement?: Determine if Client B has two units of
packed cells available in the blood bank.
20.Triage question with a train wreck The psychiatric nurse is called to a
train derailment that was likely caused by a terrorist bomb. In triaging
those in need of immediate care, what is the priority ranking for these
cases? (arrange these cases in order or priority with the top item requiring
the most immediate care and the bottom item requiring the least priority
care): A mother and father have just arrived on the .
