(NGN) HESI RN EXIT EXAM LATEST VERSION 2023
ANSWERED WITH RATIONALE {NEXT GEN FORMAT
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
c. Assume responsibility for placing the pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying
position.
(ANS- Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows
Rationale: The nurse should instruct the UAP to pad the side rails with soft
blankest because the use of pillows could result in suffocation and would need to
be removed at the onset of the seizure. The nurse can delegate paddling the side
rails to the UAP
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer.
Her Papanicolau (Pap) smear results are negative. What information should the
nurse include in the client's teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
,c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed.
(ANS- Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer
should be evaluated carefully
A client who recently underwent a tracheostomy is being prepared for discharge to
home. Which instructions is most important for the nurse to include in the
discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site.
(ANS- Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which
is critical.
In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
(ANS- Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the
client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms.
Which client alarm should the nurse investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes.
,(ANS- Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea that
should be assessed first.
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What action should the nurse take first?
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level
(ANS- Check the client for lacerations or fractures
Rationale: After the client falls, the nurse should immediately assess for the
possibility of injuries and provide first aid as needed
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at 0400 because she
wanted to avoid getting a headache. Which action should the nurse take first?
a. Ensure preoperative lab results are available
b. Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d. Contact the client's obstetrician.
(ANS- Inform the anesthesia care provider
Rationale: Surgical preoperative instruction includes NPO after midnight the day
of surgery to decrease the risk of aspiration should vomiting occur during
anesthesia. While it is possible the C-section will be done on schedule or
rescheduled for later in the day, the anesthesia provider should be notified first.
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first
a. Side the stethoscope across the sternum.
b. Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d. Observe the cardiac telemetry monitor
, (ANS- Listen with the bell at the same location
Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds
such as S3 and S4. The nurse listens at the same site using the diaphragm the
diaphragm and bell before moving systematically to the next sites.
A 66-year-old woman is retiring and will no longer have a health insurance
through her place of employment. Which agency should the client be referred to by
the employee health nurse for health insurance needs?
a. Woman, Infant, and Children program
b. Medicaid
c. Medicare
d. Consolidated Omnibus Budget Reconciliation Act provision.
(ANS- Medicare
Rationale: Title XVII of the social security Act of 1965 created Medicare Program
to provide medical insurance for person more than 65 years or older, disable or
with permeant kidney failure, WIC provides supplemental nutrition to meet the
needs of pregnant of breastfeeding woman, infants and children up to age of 6.
Medicaid provides financial assistance to pay for medical services for poor older
adults, blind, disable and families with dependent children. COBRA(D) health
benefit provisions is a limited insurance plan for those who has been laid off or
become unemployed.
A client who is taking an oral dose of a tetracycline complains of gastrointestinal
upset. What snack should the nurse instruct the client to take with the tetracycline?
a. Fruit-flavored yogurt.
b. Cheese and crackers.
c. Cold cereal with skim milk.
d. Toasted wheat bread and jelly
(ANS- Toasted wheat bread and jelly
Rationale: Dairy products decrease the effect of tetracycline, so the nurse instructs
the client to eat a snack such as toast, which contains no dairy products and may
decrease GI symptoms.
Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication?
ANSWERED WITH RATIONALE {NEXT GEN FORMAT
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
c. Assume responsibility for placing the pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying
position.
(ANS- Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows
Rationale: The nurse should instruct the UAP to pad the side rails with soft
blankest because the use of pillows could result in suffocation and would need to
be removed at the onset of the seizure. The nurse can delegate paddling the side
rails to the UAP
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer.
Her Papanicolau (Pap) smear results are negative. What information should the
nurse include in the client's teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
,c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed.
(ANS- Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer
should be evaluated carefully
A client who recently underwent a tracheostomy is being prepared for discharge to
home. Which instructions is most important for the nurse to include in the
discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site.
(ANS- Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which
is critical.
In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
(ANS- Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the
client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system alarms.
Which client alarm should the nurse investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes.
,(ANS- Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea that
should be assessed first.
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What action should the nurse take first?
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level
(ANS- Check the client for lacerations or fractures
Rationale: After the client falls, the nurse should immediately assess for the
possibility of injuries and provide first aid as needed
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at 0400 because she
wanted to avoid getting a headache. Which action should the nurse take first?
a. Ensure preoperative lab results are available
b. Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d. Contact the client's obstetrician.
(ANS- Inform the anesthesia care provider
Rationale: Surgical preoperative instruction includes NPO after midnight the day
of surgery to decrease the risk of aspiration should vomiting occur during
anesthesia. While it is possible the C-section will be done on schedule or
rescheduled for later in the day, the anesthesia provider should be notified first.
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first
a. Side the stethoscope across the sternum.
b. Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d. Observe the cardiac telemetry monitor
, (ANS- Listen with the bell at the same location
Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds
such as S3 and S4. The nurse listens at the same site using the diaphragm the
diaphragm and bell before moving systematically to the next sites.
A 66-year-old woman is retiring and will no longer have a health insurance
through her place of employment. Which agency should the client be referred to by
the employee health nurse for health insurance needs?
a. Woman, Infant, and Children program
b. Medicaid
c. Medicare
d. Consolidated Omnibus Budget Reconciliation Act provision.
(ANS- Medicare
Rationale: Title XVII of the social security Act of 1965 created Medicare Program
to provide medical insurance for person more than 65 years or older, disable or
with permeant kidney failure, WIC provides supplemental nutrition to meet the
needs of pregnant of breastfeeding woman, infants and children up to age of 6.
Medicaid provides financial assistance to pay for medical services for poor older
adults, blind, disable and families with dependent children. COBRA(D) health
benefit provisions is a limited insurance plan for those who has been laid off or
become unemployed.
A client who is taking an oral dose of a tetracycline complains of gastrointestinal
upset. What snack should the nurse instruct the client to take with the tetracycline?
a. Fruit-flavored yogurt.
b. Cheese and crackers.
c. Cold cereal with skim milk.
d. Toasted wheat bread and jelly
(ANS- Toasted wheat bread and jelly
Rationale: Dairy products decrease the effect of tetracycline, so the nurse instructs
the client to eat a snack such as toast, which contains no dairy products and may
decrease GI symptoms.
Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication?
