Hesi Exit Exam 2023, With Complete Verified
Solution
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
An elderly male client is experiencing urinary incontinence. What is the best
initial nursing action?
Apply an external condom catheter
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
UAP using a hand sanitzers that is alcohol for 2 minutes
tell that hand sanitizer use is less > 2min
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. 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
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
Within four weeks of childbirth, a client is admitted to the hospital for
disorganized speech bizarre behavior, and strange thoughts about her infant
being possessed by demons. The nurse identifies a nursing diagnosis of "Altered
thought processes, secondary to" what condition?
Postpartum psychosis
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.
Psych/Alcohol/Tylenol overdose antidote
Give Mucomyst
Medical Surgical/Laxative abuses
, Patient -taking Milk of Magnesium
Spiritual/Documentation
Native American - Allow pt's family to stay in the room
Leadership- Interpreter informed consent
Pt should sign the consent
Geriatrics/Emergency Rib fractures fall
Pulmonary embolism
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
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
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.
After administering a medication through a nasogastric tube connected to
suction, what action should the nurse take first?
Clamp the tube
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.
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 .
A crying child being held by another passenger. A woman sitting on the ground with a
blanket.
A middle-aged man who is wandering around
(arrange in order) = middle age woman bleeding- woman w/ blanket- child crying-
mother and father. (Mine didn't have a middle age woman bleeding, instead it had
an old man wandering and
correct order is: wandering old man, woman w/blanket, man holding baby, and mother &
father)
The nurse in the emergency department is using the simple triage and rapid
transport (START) system to assess victims of a hurricane. Which statement
correctly describes a yellow disaster tag?
Solution
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
An elderly male client is experiencing urinary incontinence. What is the best
initial nursing action?
Apply an external condom catheter
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
UAP using a hand sanitzers that is alcohol for 2 minutes
tell that hand sanitizer use is less > 2min
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. 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
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
Within four weeks of childbirth, a client is admitted to the hospital for
disorganized speech bizarre behavior, and strange thoughts about her infant
being possessed by demons. The nurse identifies a nursing diagnosis of "Altered
thought processes, secondary to" what condition?
Postpartum psychosis
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.
Psych/Alcohol/Tylenol overdose antidote
Give Mucomyst
Medical Surgical/Laxative abuses
, Patient -taking Milk of Magnesium
Spiritual/Documentation
Native American - Allow pt's family to stay in the room
Leadership- Interpreter informed consent
Pt should sign the consent
Geriatrics/Emergency Rib fractures fall
Pulmonary embolism
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
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
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.
After administering a medication through a nasogastric tube connected to
suction, what action should the nurse take first?
Clamp the tube
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.
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 .
A crying child being held by another passenger. A woman sitting on the ground with a
blanket.
A middle-aged man who is wandering around
(arrange in order) = middle age woman bleeding- woman w/ blanket- child crying-
mother and father. (Mine didn't have a middle age woman bleeding, instead it had
an old man wandering and
correct order is: wandering old man, woman w/blanket, man holding baby, and mother &
father)
The nurse in the emergency department is using the simple triage and rapid
transport (START) system to assess victims of a hurricane. Which statement
correctly describes a yellow disaster tag?
