INTERGRATED RN HESI EXIT EXAM COMPLETE QUESTIONS
AND ANSWERS 2024 - VERSION IV
1. The family wish to see the body before it is taken to the funeral home. Which
interventions should the nurse take to prepare the body before the family enters the
room? (Select all that apply)
a- Take out dentures and place in a labeled
cupb- Apply a body shroud
• Place a small pillow under the head
• Remove resuscitation equipment from the
roome- Gently close the eyes
A client with major depression who is taking fluoxetine calls the psychiatric clinic
reporting being more agitated, irritable, and anxious than usual. Which intervention
should the nurse implement?
a- Tell the client to have a complete blood count (CBC)
drawnb- Instruct the client to seek medical attention
immediately
• Encourage him to take the medication at night with a snack
• Explain that these are common side effects of the medication
A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days.
Which finding indicates to the nurse that the medication is effective?
a- Granulating tissue in foot
ulcerb- Full volume of pedal
pulse
• Reduced level of pain
• Improved visual activity.
The nurse is assessing a client with Addison's disease who is weak, dizzy,
disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes.
Vital signs areblood pressure 94/44, heart rate 123 beats/minute, respiration 22
breaths/minute.
Which intervention should the nurse implement
first?c- Measure and record the cardiac QRS
complex
• Assess extremity strength and resistance
• Report a sodium level of 132 mEq/L or mmol/L (SI
units) d- Check current finger stick glucose
A 41-week gestation primigravida woman is admitted to labor and delivery for
induction of labor. What finding should the nurse report to the healthcare provider
before initiatingthe infusion of oxytocin?
• Fetal heart tones located in upper right quadrant
,• Biophysical profile results showing
oligohydramnios c- Regular contractions occurring
every 10 minutes
d- d- Sterile vaginal exam reveling 3 cm dilatation
A client in the intensive care unit is being mechanically ventilated, has an indwelling
urinary catheter in place, and is exhibiting signs of restlessness. Which action
shouldthe nurse take first?
a- Review the heart rhythm on cardiac
monitorsb- Check urinary catheter for
obstruction
• Auscultated bilateral breath sounds
• Give PRN dose of lorazepam (Ativan))
When assessing a client with acute asthma, the nurse is most likely to obtain which
finding?
a- Pursed lip breathing and clubbing of fingers b- Fever and a high- pitched
inspiratorystridor
• A short expiratory phase and hemoptysis
• Cough and musical breath sound on expiration
The nurse is caring for a newborn who arrives in the nursery following a precipitous
birth on the way to the hospital. A drug screen of the mother reveals the presence of
cocaine metabolites. The infant has a heart rate of 175 beats/ minute, cries
continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most
important for the nurse to include in this infant's plan of care?
• Initiate infant sepsis protocol
• Implements seizure
precautions c Refer to protective
child services d- Formula feed
every 3 hours
A client collapses while showering and is found discovered by the nurse while
makingrounds. The client is not breathing and does not have a palpable pulse. The
nurse obtains the Automated External Defibrillator (AED). What action should the
nurse implement next?
• Follow the prompts of the AED
• Apply the AED pads to the client's chest
c- Wipe the client's chest dry
d- Move the client from the bathroom
After a motor vehicle collision, a client admitted to the medical unit with acute adrenal
insufficiency (Addisonian crisis). Which prescription should the nurse implement?
• Determine serum glucose levels
, • Withhold potassium additives to IV
fluidsc- Give IV corticosteroid
replacement
d- Prepare to initiate IV vasopressors
Assessment by the home health nurse of an older client who lives alone indicates that
client has chronic constipations. Daily medications include furosemide for
hypertension and heart failure and laxatives. To manage the client's constipation,
which suggestionsshould the nurse provide? (Select all that apply)
a- Decrease laxative use to every other day, and use oil retention enemas as
needed.b- Include oatmeal with stewed pruned for breakfast as often as possible.
• Increase fluid intake by keeping water glass next to recliner.
• Recommend seeking help with regular shopping and meal preparation.
• Report constipation to healthcare provider related to cardiac medication side effects.
A 5-week-old infant who developed projectile vomiting over the last two weeks is
diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse
planto implement?
a- Instruct the mother to give the child sugar water
onlyb- Maintain intravenous fluid therapy per
prescription
c- Provide Pedialyte feedings via the nasogastric
tubed- Offer the infant Pedialyte feedings every 2
hours.
A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which
intervention is most important for the nurse to include in this client's plan of care?
a- Observe for bleeding side effects related to heparin
therapy.b- b- Assess blood pressure and heart rate at least
q4 hours
c- c- Measure calf girths to evaluate edema in the affected
legd- Encourage mobilization to prevent pulmonary
embolism
Prior to surgery, written consent must be obtained. What is the nurse's legal
responsibility with regard to obtaining written consent?
• Validate the clients understanding of the surgical procedure to be conducted
• Explain the surgical procedure to the client ask the client to sign the consent
formc- Ask the client or a family member to sign the surgical consent form
d- Determine that the surgical consent form has been signed and is included in the
client's record
What is the primary focus of postoperative nursing care for the client with colon
trauma? a- Monitoring for elevated coagulation studies
AND ANSWERS 2024 - VERSION IV
1. The family wish to see the body before it is taken to the funeral home. Which
interventions should the nurse take to prepare the body before the family enters the
room? (Select all that apply)
a- Take out dentures and place in a labeled
cupb- Apply a body shroud
• Place a small pillow under the head
• Remove resuscitation equipment from the
roome- Gently close the eyes
A client with major depression who is taking fluoxetine calls the psychiatric clinic
reporting being more agitated, irritable, and anxious than usual. Which intervention
should the nurse implement?
a- Tell the client to have a complete blood count (CBC)
drawnb- Instruct the client to seek medical attention
immediately
• Encourage him to take the medication at night with a snack
• Explain that these are common side effects of the medication
A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days.
Which finding indicates to the nurse that the medication is effective?
a- Granulating tissue in foot
ulcerb- Full volume of pedal
pulse
• Reduced level of pain
• Improved visual activity.
The nurse is assessing a client with Addison's disease who is weak, dizzy,
disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes.
Vital signs areblood pressure 94/44, heart rate 123 beats/minute, respiration 22
breaths/minute.
Which intervention should the nurse implement
first?c- Measure and record the cardiac QRS
complex
• Assess extremity strength and resistance
• Report a sodium level of 132 mEq/L or mmol/L (SI
units) d- Check current finger stick glucose
A 41-week gestation primigravida woman is admitted to labor and delivery for
induction of labor. What finding should the nurse report to the healthcare provider
before initiatingthe infusion of oxytocin?
• Fetal heart tones located in upper right quadrant
,• Biophysical profile results showing
oligohydramnios c- Regular contractions occurring
every 10 minutes
d- d- Sterile vaginal exam reveling 3 cm dilatation
A client in the intensive care unit is being mechanically ventilated, has an indwelling
urinary catheter in place, and is exhibiting signs of restlessness. Which action
shouldthe nurse take first?
a- Review the heart rhythm on cardiac
monitorsb- Check urinary catheter for
obstruction
• Auscultated bilateral breath sounds
• Give PRN dose of lorazepam (Ativan))
When assessing a client with acute asthma, the nurse is most likely to obtain which
finding?
a- Pursed lip breathing and clubbing of fingers b- Fever and a high- pitched
inspiratorystridor
• A short expiratory phase and hemoptysis
• Cough and musical breath sound on expiration
The nurse is caring for a newborn who arrives in the nursery following a precipitous
birth on the way to the hospital. A drug screen of the mother reveals the presence of
cocaine metabolites. The infant has a heart rate of 175 beats/ minute, cries
continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most
important for the nurse to include in this infant's plan of care?
• Initiate infant sepsis protocol
• Implements seizure
precautions c Refer to protective
child services d- Formula feed
every 3 hours
A client collapses while showering and is found discovered by the nurse while
makingrounds. The client is not breathing and does not have a palpable pulse. The
nurse obtains the Automated External Defibrillator (AED). What action should the
nurse implement next?
• Follow the prompts of the AED
• Apply the AED pads to the client's chest
c- Wipe the client's chest dry
d- Move the client from the bathroom
After a motor vehicle collision, a client admitted to the medical unit with acute adrenal
insufficiency (Addisonian crisis). Which prescription should the nurse implement?
• Determine serum glucose levels
, • Withhold potassium additives to IV
fluidsc- Give IV corticosteroid
replacement
d- Prepare to initiate IV vasopressors
Assessment by the home health nurse of an older client who lives alone indicates that
client has chronic constipations. Daily medications include furosemide for
hypertension and heart failure and laxatives. To manage the client's constipation,
which suggestionsshould the nurse provide? (Select all that apply)
a- Decrease laxative use to every other day, and use oil retention enemas as
needed.b- Include oatmeal with stewed pruned for breakfast as often as possible.
• Increase fluid intake by keeping water glass next to recliner.
• Recommend seeking help with regular shopping and meal preparation.
• Report constipation to healthcare provider related to cardiac medication side effects.
A 5-week-old infant who developed projectile vomiting over the last two weeks is
diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse
planto implement?
a- Instruct the mother to give the child sugar water
onlyb- Maintain intravenous fluid therapy per
prescription
c- Provide Pedialyte feedings via the nasogastric
tubed- Offer the infant Pedialyte feedings every 2
hours.
A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which
intervention is most important for the nurse to include in this client's plan of care?
a- Observe for bleeding side effects related to heparin
therapy.b- b- Assess blood pressure and heart rate at least
q4 hours
c- c- Measure calf girths to evaluate edema in the affected
legd- Encourage mobilization to prevent pulmonary
embolism
Prior to surgery, written consent must be obtained. What is the nurse's legal
responsibility with regard to obtaining written consent?
• Validate the clients understanding of the surgical procedure to be conducted
• Explain the surgical procedure to the client ask the client to sign the consent
formc- Ask the client or a family member to sign the surgical consent form
d- Determine that the surgical consent form has been signed and is included in the
client's record
What is the primary focus of postoperative nursing care for the client with colon
trauma? a- Monitoring for elevated coagulation studies
