2018/2019 REAL HESI EXIT EXAM V2b 160 QUESTIONS AND
ANSWERS WITH THE EXPERTVERIFIED SOLUTIONS
GRADED A+
• The nurse knows that which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4 year-old
child?
• "I strap the infant car seat on the front seat to face backwards."
• "I place my infant in the middle of the living room floor on a blanket to play with
my4 year old while I make supper in the kitchen."
• "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the
airwhile the four year old naps on the sofa."
• "I have the 4 year-old hold and help feed the four month-old a bottle in the
kitchenwhile I make supper."
The correct answer is D: "I have the four year-old hold and help feed the four month-old
a bottle in the kitchen
• Upon completing the admission documents, the nurse learns that the 87 year-old
clientdoes not have an advance directive. What action should the nurse take?
• Record the information on the chart
• Give information about advance directives
• Assume that this client wishes a full code
• Refer this issue to the unit secretary
The correct answer is B: Give information about advance directives
• A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes
afterthe immunization was given, the client complains of itchy and watery eyes, increased
anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of
care for this client will be to
• Maintain the airway
• Administer epinephrine 1:1000 as ordered
• Monitor for hypotension with shock
• Administer diphenhydramine as ordered
The correct answer is B: Administer epinephrine 1:1000 as ordered .
• Which of these children at the site of a disaster at a child day care center would
thetriage nurse put in the "treat last" category?
• An infant with intermittent bulging anterior fontanel between crying episodes
• A toddler with severe deep abrasions over 98% of the body
,• A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
• A school-age child with singed eyebrows and hair on the arms
The correct answer is B: A toddler with severe deep abrasions over 98% of the body .
• When admitting a client to an acute care facility, an identification bracelet is sent up
with the admission form. In the event these do not match, the nurse’s best action is to
• Change whichever item is incorrect to the correct information
• Use the bracelet and admission form until a replacement is supplied
• Notify the admissions office and wait to apply the bracelet
• Make a corrected identification bracelet for the client
The correct answer is C: notify the admissions office and wait to apply the bracelet
• The nurse is having difficulty reading the health care provider's written order that
waswritten right before the shift change. What action should be taken?
• Leave the order for the oncoming staff to follow-up
• Contact the charge nurse for an interpretation
• Ask the pharmacy for assistance in the interpretation
• Call the provider for clarification
The correct answer is D: Call the provider for clarification
• An adult client is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the nurse
isto:
• check the carotid pulse
• deliver 5 abdominal thrusts
• give 2 rescue breaths
• open the client's airway
The correct answer is D: open the client''s airway
• A client has an order for 1000 ml of D5W over an 8 hour period. The nurse
discoversthat 800 ml has been infused after 4 hours. What is the priority nursing action?
• Ask the client if there are any breathing problems
• Have the client void as much as possible
• Check the vital signs
• Auscultate the lungs
The correct answer is D: Auscultate the lungs
• Following change-of-shift report on an orthopedic unit, which client should the
nursesee first?
• 16 year-old who had an open reduction of a fractured wrist 10 hours ago
• 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
,• 72 year-old recovering from surgery after a hip replacement 2 hours ago
• 75 year-old who is in skin traction prior to planned hip pinning surgery.
The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2
hours ago
• A nurse observes a family member administer a rectal suppository by having the
client lie on the left side for the administration. The family member pushed the
suppository until the finger went up to the second knuckle. After 10 minutes the client
was told by the family member to turn to the right side and the client did this. What is
theappropriate comment for the nurse to make?
• Why don’t we now have the client turn back to the left side.
• That was done correctly. Did you have any problems with the insertion?
• Let’s check to see if the suppository is in far enough.
• Did you feel any stool in the intestinal tract?
The correct answer is B: That was done correctly. Did you have any problems with the
insertion?
• A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA)
hasdied. Which type of precautions is the appropriate type to use when performing
postmortem care?
• airborne precautions
• droplet precautions
• contact precautions
• compromised host precautions
The correct answer is C: contact precautions
• The nurse is reviewing with a client how to collect a clean catch urine
specimen.Which sequence is appropriate teaching?
• Void a little, clean the meatus, then collect specimen
• clean the meatus, begin voiding, then catch urine stream
• Clean the meatus, then urinate into container
• Void continuously and catch some of the urine
The correct answer is B: clean the meatus, begin voiding, then catch urine stream
• The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every
day. Which of these foods would the nurse reinforce for the client to eat at least daily?
• spaghetti
• watermelon
• chicken
• tomatoes
, The correct answer is B: watermelon
• A nurse is stuck in the hand by an exposed needle. What immediate action should
thenurse take?
• Look up the policy on needle sticks
• Contact employee health services
• Immediately wash the hands with vigor
• Notify the supervisor and risk management
The correct answer is C: Immediately wash the hands with vigor
• As the nurse observes the student nurse during the administration of a narcotic
analgesic IM injection, the nurse notes that the student begins to give the
medicationwithout first aspirating. What should the nurse do?
• Ask the student: "What did you forget to do?”
• Stop. Tell me why aspiration is needed.
• Loudly state: “You forgot to aspirate.”
• Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”
The correct answer is D: Walk up and whisper in the student’s ear “Stop. Aspirate. Then
inject.”
• A client with Guillain Barre is in a non responsive state, yet vital signs are stable
andbreathing is independent. What should the nurse document to most accurately
describe the client's condition?
• Comatose, breathing unlabored
• Glascow Coma Scale 8, respirations regular
• Appears to be sleeping, vital signs stable
• Glascow Coma Scale 13, no ventilator required
The correct answer is B: Glascow Coma Scale 8, respirations regular
• A client enters the emergency department unconscious via ambulance from the
client’s work place. What document should be given priority to guide the direction of
carefor this client?
• The statement of client rights and the client self determination act
• Orders written by the health care provider
• A notarized original of advance directives brought in by the partner
• The clinical pathway protocol of the agency and the emergency department
The correct answer is C: A notarized original of advance directives brought in by the
partner
ANSWERS WITH THE EXPERTVERIFIED SOLUTIONS
GRADED A+
• The nurse knows that which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4 year-old
child?
• "I strap the infant car seat on the front seat to face backwards."
• "I place my infant in the middle of the living room floor on a blanket to play with
my4 year old while I make supper in the kitchen."
• "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the
airwhile the four year old naps on the sofa."
• "I have the 4 year-old hold and help feed the four month-old a bottle in the
kitchenwhile I make supper."
The correct answer is D: "I have the four year-old hold and help feed the four month-old
a bottle in the kitchen
• Upon completing the admission documents, the nurse learns that the 87 year-old
clientdoes not have an advance directive. What action should the nurse take?
• Record the information on the chart
• Give information about advance directives
• Assume that this client wishes a full code
• Refer this issue to the unit secretary
The correct answer is B: Give information about advance directives
• A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes
afterthe immunization was given, the client complains of itchy and watery eyes, increased
anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of
care for this client will be to
• Maintain the airway
• Administer epinephrine 1:1000 as ordered
• Monitor for hypotension with shock
• Administer diphenhydramine as ordered
The correct answer is B: Administer epinephrine 1:1000 as ordered .
• Which of these children at the site of a disaster at a child day care center would
thetriage nurse put in the "treat last" category?
• An infant with intermittent bulging anterior fontanel between crying episodes
• A toddler with severe deep abrasions over 98% of the body
,• A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
• A school-age child with singed eyebrows and hair on the arms
The correct answer is B: A toddler with severe deep abrasions over 98% of the body .
• When admitting a client to an acute care facility, an identification bracelet is sent up
with the admission form. In the event these do not match, the nurse’s best action is to
• Change whichever item is incorrect to the correct information
• Use the bracelet and admission form until a replacement is supplied
• Notify the admissions office and wait to apply the bracelet
• Make a corrected identification bracelet for the client
The correct answer is C: notify the admissions office and wait to apply the bracelet
• The nurse is having difficulty reading the health care provider's written order that
waswritten right before the shift change. What action should be taken?
• Leave the order for the oncoming staff to follow-up
• Contact the charge nurse for an interpretation
• Ask the pharmacy for assistance in the interpretation
• Call the provider for clarification
The correct answer is D: Call the provider for clarification
• An adult client is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the nurse
isto:
• check the carotid pulse
• deliver 5 abdominal thrusts
• give 2 rescue breaths
• open the client's airway
The correct answer is D: open the client''s airway
• A client has an order for 1000 ml of D5W over an 8 hour period. The nurse
discoversthat 800 ml has been infused after 4 hours. What is the priority nursing action?
• Ask the client if there are any breathing problems
• Have the client void as much as possible
• Check the vital signs
• Auscultate the lungs
The correct answer is D: Auscultate the lungs
• Following change-of-shift report on an orthopedic unit, which client should the
nursesee first?
• 16 year-old who had an open reduction of a fractured wrist 10 hours ago
• 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
,• 72 year-old recovering from surgery after a hip replacement 2 hours ago
• 75 year-old who is in skin traction prior to planned hip pinning surgery.
The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2
hours ago
• A nurse observes a family member administer a rectal suppository by having the
client lie on the left side for the administration. The family member pushed the
suppository until the finger went up to the second knuckle. After 10 minutes the client
was told by the family member to turn to the right side and the client did this. What is
theappropriate comment for the nurse to make?
• Why don’t we now have the client turn back to the left side.
• That was done correctly. Did you have any problems with the insertion?
• Let’s check to see if the suppository is in far enough.
• Did you feel any stool in the intestinal tract?
The correct answer is B: That was done correctly. Did you have any problems with the
insertion?
• A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA)
hasdied. Which type of precautions is the appropriate type to use when performing
postmortem care?
• airborne precautions
• droplet precautions
• contact precautions
• compromised host precautions
The correct answer is C: contact precautions
• The nurse is reviewing with a client how to collect a clean catch urine
specimen.Which sequence is appropriate teaching?
• Void a little, clean the meatus, then collect specimen
• clean the meatus, begin voiding, then catch urine stream
• Clean the meatus, then urinate into container
• Void continuously and catch some of the urine
The correct answer is B: clean the meatus, begin voiding, then catch urine stream
• The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every
day. Which of these foods would the nurse reinforce for the client to eat at least daily?
• spaghetti
• watermelon
• chicken
• tomatoes
, The correct answer is B: watermelon
• A nurse is stuck in the hand by an exposed needle. What immediate action should
thenurse take?
• Look up the policy on needle sticks
• Contact employee health services
• Immediately wash the hands with vigor
• Notify the supervisor and risk management
The correct answer is C: Immediately wash the hands with vigor
• As the nurse observes the student nurse during the administration of a narcotic
analgesic IM injection, the nurse notes that the student begins to give the
medicationwithout first aspirating. What should the nurse do?
• Ask the student: "What did you forget to do?”
• Stop. Tell me why aspiration is needed.
• Loudly state: “You forgot to aspirate.”
• Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”
The correct answer is D: Walk up and whisper in the student’s ear “Stop. Aspirate. Then
inject.”
• A client with Guillain Barre is in a non responsive state, yet vital signs are stable
andbreathing is independent. What should the nurse document to most accurately
describe the client's condition?
• Comatose, breathing unlabored
• Glascow Coma Scale 8, respirations regular
• Appears to be sleeping, vital signs stable
• Glascow Coma Scale 13, no ventilator required
The correct answer is B: Glascow Coma Scale 8, respirations regular
• A client enters the emergency department unconscious via ambulance from the
client’s work place. What document should be given priority to guide the direction of
carefor this client?
• The statement of client rights and the client self determination act
• Orders written by the health care provider
• A notarized original of advance directives brought in by the partner
• The clinical pathway protocol of the agency and the emergency department
The correct answer is C: A notarized original of advance directives brought in by the
partner
