HESI RN EXIT EXAM 2024 TEST BANK ACTUAL EXAM
QUESTIONS WITH DETAILED VERIFIED ANSWERS AND
RATIONALE /A+ GRADE ASSURED (UPDATED)
The nurse is completing the admission assessment of a 3-year old who is admitted with
bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child
is experiencing increased intracranial pressure (ICP)?
• Tachycardia and tachypnea
• Sluggish and unequal pupillary responses
• Increased head circumference and bulging fontanels
• Blood pressure fluctuations and syncope - Correct answer-B. Sluggish and unequal
pupillary responses
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an
elevated serum amylase. Which additional information is the client most likely to report to
the nurse?
• Abdominal pain decreases when lying supine
• Pain lasts an hour and leaves the abdomen tender
• C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly. - Correct answer-A. Abdominal
pain decreases when lying supine
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the
hospital. Which information is most important for the nurse to provide the parents priorto
discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family - Correct answer-A. Instructions
about how much fluid the child should drink daily
To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select
the location on the image with a red dot). - Correct answer-I placed the red doton the base
of the neck on the right side
After receiving report on an inpatient acute care unit, which client should the nurseassess
first?
• The client with an obstruction of the large intestine who is experiencing abdominal
distention
• The client who had surgery yesterday and is experiencing a paralytic ileus with
absent bowel sounds
• The client with a small bowel obstruction who has a nasogastric tube that is draining
greenish fluid
,• The client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity - Correct answer-D. The client with a bowel obstruction due to a volvulus who is
experiencing abdominal rigidity
A teenager presents to the emergency department with palpitations after vaping at aparty.
The client is anxious, fearful, and hyperventilating. The nurse anticipates the client
developing which acid base imbalance?
A. Respiratory
acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis - Correct answer-D. Respiratory alkalosis
A client with dyspnea is being admitted to the medical unit. To best prepare for the
client's arrival, the nurse should ensure that the client's bed is in which position?
• Supine
• supine; feet elevated higher than head
• C. supine; head elevated higher than
feet
• D. Fowlers - Correct answer-Fowlers
The nurse is taking the blood pressure measurement of a client with Parkinson's
disease. Which information in the client's admission assessment is relevant to the
nurse's plan for taking the blood pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling - Correct answer-A. Frequent syncopeC.
Flat affect
D. Blurred vision
While caring for a client's postoperative dressing, the nurse observes purulent drainageat the
wound. Before reporting this finding to the healthcare provider, the nurse should review
which of the client's laboratory values?
• Serum albumin
• Culture for sensitive organisms
• C. Serum blood glucose level
D. Creatinine level - Correct answer-B. Culture for sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following successful resuscitationfrom
a near-drowning incident. While providing care to the child, the nurse begins talking with his
preadolescent brother who rescued the child from the swimming pool and initiated
resuscitation. The nurse notices the older boy becomes withdrawn when asked about what
happened. Which action should the nurse take?
A. Develop a water safety teaching plan for the family
,B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions - Correct answer-B. Ask the older
brother how he felt during the incident
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been
soaking in hot baths at night with no relief of his discomfort. Which action shouldthe nurse
take?
• Encourage the client to use cooler water and apply calamine lotion after soaking
• Obtain a PRN prescription for an analgesic that the client can use for symptom relief
• C. Suggest that the client take brief showers and apply oil-based lotion after showering
• D. Explain that the symptoms are caused by liver damage and cannot be relieved -
Correct answer-A. Encourage the client to use cooler water and apply calamine lotion after
soaking
An older client with a long history of coronary artery disease (CAD), hypertension (HTN),
and heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The
healthcare provider prescribes furosemide IV. Which therapeutic responseto furosemide
should the nurse expected in the client with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload - Correct answer-B. Reduced preload
Which intervention should the nurse include in the plan of care for a child with tetanus?
A. Encourage coughing and deep breathing
B. Minimize the amount of stimuli in the room
C. Reposition from side to side every hour
D. Open window shades to provide natural light - Correct answer-B. Minimize the
amount of stimuli in the room
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted
to the hospital in diabetic ketoacidosis. Which occurrence is the most likelycause of the
ketoacidosis?
A. Ate an extra peanut butter sandwich before gym class
B. incorrectly administered too much insulin
C. Had a cold and ear infection for the past two days
D. Skipped eating lunch - Correct answer-C. Had a cold and ear infection for the pasttwo
days
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of
impending death. After notifying the family of the client's status, what priority action should
the nurse implement?
A. The impending signs of death should be documented
B. The client's status should be conveyed to the chaplain
, C. The client's need for pain medication should be determined
D. The nurse manager should be updated on the client's status - Correct answer-C. Theclient's
need for pain medication should be determined
Which self care measure is most important for the nurse to include in the plan of care ofa
client recently diagnosed with type 2 diabetes mellitus?
A. Self-injection techniques
B. Blood glucose monitoring
C. Diabetic diet meal
planning
D. A realistic exercise plan - Correct answer-B. Blood glucose monitoring
A client who gave birth 48 hours ago has decided to bottle feed the infant. During the
assessment, the nurse observes that both breasts are swollen, warm, and tender on
palpation. Which instruction should the nurse provide?
• Apply ice to the breasts for comfort
• Wear a loose-fitting bra during the day to prevent nipple irritation
• C. Run warm water over breasts
D. Express small amounts of milk from the breasts to relieve pressure - Correct answer-A.
Apply ice to the breasts for comfort
The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to
home. Which recommendations should the nurse provide this client?(Select all that apply)
A. Avoid range of motion exercises
B. Use a residual limb shrinker
C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
E. Wash the stump with soap and water - Correct answer-B. Use a residual limb
shrinker
D. Inspect skin for redness
E. Wash the stump with soap and water
A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and
vomiting that occurs after ingesting of milk products arrives to the clinic accompanied by the
parents. Which type of testing should the nurse provide educationto the toddler's family
about?
A. Serum immunoglobulin E
(IgE)B. Intradermal test
C. Atopy patch test
D. Placebo-controlled food challenge - Correct answer-A. Serum immunoglobulin E
(IgE)
A client who is scheduled for a bronchoscopy in the morning is anxious and asking thenurse
numerous questions about the procedure. In preparing the client for the procedure, which
intervention has the highest priority?
A. Allow client to gargle with warm salt water
QUESTIONS WITH DETAILED VERIFIED ANSWERS AND
RATIONALE /A+ GRADE ASSURED (UPDATED)
The nurse is completing the admission assessment of a 3-year old who is admitted with
bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child
is experiencing increased intracranial pressure (ICP)?
• Tachycardia and tachypnea
• Sluggish and unequal pupillary responses
• Increased head circumference and bulging fontanels
• Blood pressure fluctuations and syncope - Correct answer-B. Sluggish and unequal
pupillary responses
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an
elevated serum amylase. Which additional information is the client most likely to report to
the nurse?
• Abdominal pain decreases when lying supine
• Pain lasts an hour and leaves the abdomen tender
• C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly. - Correct answer-A. Abdominal
pain decreases when lying supine
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the
hospital. Which information is most important for the nurse to provide the parents priorto
discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family - Correct answer-A. Instructions
about how much fluid the child should drink daily
To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select
the location on the image with a red dot). - Correct answer-I placed the red doton the base
of the neck on the right side
After receiving report on an inpatient acute care unit, which client should the nurseassess
first?
• The client with an obstruction of the large intestine who is experiencing abdominal
distention
• The client who had surgery yesterday and is experiencing a paralytic ileus with
absent bowel sounds
• The client with a small bowel obstruction who has a nasogastric tube that is draining
greenish fluid
,• The client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity - Correct answer-D. The client with a bowel obstruction due to a volvulus who is
experiencing abdominal rigidity
A teenager presents to the emergency department with palpitations after vaping at aparty.
The client is anxious, fearful, and hyperventilating. The nurse anticipates the client
developing which acid base imbalance?
A. Respiratory
acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis - Correct answer-D. Respiratory alkalosis
A client with dyspnea is being admitted to the medical unit. To best prepare for the
client's arrival, the nurse should ensure that the client's bed is in which position?
• Supine
• supine; feet elevated higher than head
• C. supine; head elevated higher than
feet
• D. Fowlers - Correct answer-Fowlers
The nurse is taking the blood pressure measurement of a client with Parkinson's
disease. Which information in the client's admission assessment is relevant to the
nurse's plan for taking the blood pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling - Correct answer-A. Frequent syncopeC.
Flat affect
D. Blurred vision
While caring for a client's postoperative dressing, the nurse observes purulent drainageat the
wound. Before reporting this finding to the healthcare provider, the nurse should review
which of the client's laboratory values?
• Serum albumin
• Culture for sensitive organisms
• C. Serum blood glucose level
D. Creatinine level - Correct answer-B. Culture for sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following successful resuscitationfrom
a near-drowning incident. While providing care to the child, the nurse begins talking with his
preadolescent brother who rescued the child from the swimming pool and initiated
resuscitation. The nurse notices the older boy becomes withdrawn when asked about what
happened. Which action should the nurse take?
A. Develop a water safety teaching plan for the family
,B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions - Correct answer-B. Ask the older
brother how he felt during the incident
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been
soaking in hot baths at night with no relief of his discomfort. Which action shouldthe nurse
take?
• Encourage the client to use cooler water and apply calamine lotion after soaking
• Obtain a PRN prescription for an analgesic that the client can use for symptom relief
• C. Suggest that the client take brief showers and apply oil-based lotion after showering
• D. Explain that the symptoms are caused by liver damage and cannot be relieved -
Correct answer-A. Encourage the client to use cooler water and apply calamine lotion after
soaking
An older client with a long history of coronary artery disease (CAD), hypertension (HTN),
and heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The
healthcare provider prescribes furosemide IV. Which therapeutic responseto furosemide
should the nurse expected in the client with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload - Correct answer-B. Reduced preload
Which intervention should the nurse include in the plan of care for a child with tetanus?
A. Encourage coughing and deep breathing
B. Minimize the amount of stimuli in the room
C. Reposition from side to side every hour
D. Open window shades to provide natural light - Correct answer-B. Minimize the
amount of stimuli in the room
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted
to the hospital in diabetic ketoacidosis. Which occurrence is the most likelycause of the
ketoacidosis?
A. Ate an extra peanut butter sandwich before gym class
B. incorrectly administered too much insulin
C. Had a cold and ear infection for the past two days
D. Skipped eating lunch - Correct answer-C. Had a cold and ear infection for the pasttwo
days
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of
impending death. After notifying the family of the client's status, what priority action should
the nurse implement?
A. The impending signs of death should be documented
B. The client's status should be conveyed to the chaplain
, C. The client's need for pain medication should be determined
D. The nurse manager should be updated on the client's status - Correct answer-C. Theclient's
need for pain medication should be determined
Which self care measure is most important for the nurse to include in the plan of care ofa
client recently diagnosed with type 2 diabetes mellitus?
A. Self-injection techniques
B. Blood glucose monitoring
C. Diabetic diet meal
planning
D. A realistic exercise plan - Correct answer-B. Blood glucose monitoring
A client who gave birth 48 hours ago has decided to bottle feed the infant. During the
assessment, the nurse observes that both breasts are swollen, warm, and tender on
palpation. Which instruction should the nurse provide?
• Apply ice to the breasts for comfort
• Wear a loose-fitting bra during the day to prevent nipple irritation
• C. Run warm water over breasts
D. Express small amounts of milk from the breasts to relieve pressure - Correct answer-A.
Apply ice to the breasts for comfort
The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to
home. Which recommendations should the nurse provide this client?(Select all that apply)
A. Avoid range of motion exercises
B. Use a residual limb shrinker
C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
E. Wash the stump with soap and water - Correct answer-B. Use a residual limb
shrinker
D. Inspect skin for redness
E. Wash the stump with soap and water
A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and
vomiting that occurs after ingesting of milk products arrives to the clinic accompanied by the
parents. Which type of testing should the nurse provide educationto the toddler's family
about?
A. Serum immunoglobulin E
(IgE)B. Intradermal test
C. Atopy patch test
D. Placebo-controlled food challenge - Correct answer-A. Serum immunoglobulin E
(IgE)
A client who is scheduled for a bronchoscopy in the morning is anxious and asking thenurse
numerous questions about the procedure. In preparing the client for the procedure, which
intervention has the highest priority?
A. Allow client to gargle with warm salt water
