HESI RN EXIT EXAM
The nurse is giving preop instructions to a 14 yr old scheduled to correct a spinal curvature. Which
statement best demonstrates that learning has taken place?
I understand I will be in a body cast and I will show you hoy you taught me to turn
To take the vital signs of a 4 month old child which order will give the most accurate results?
Respiratory rate, heart rate, rectal temperature
AN otoscope exam of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging
and not movable. What action should the nurse take next?
Ask the child if he has has a cold, runny nose or any ear pain lately
Which restraint should be used for a toddler after a cleft palate repair?
elbow
What preoperative nursing intervention should be included in the plan of care for an infant with
pyloric stenosis?
Observe for projectile vomiting
A six month old returns from surgery with elbow restraints in place. What nursing intervention should
be included when caring for any restrained child?
remove restraints one at a time and provide range of motion exercise
A two year old with Down Syndrome is brought to the clinic for his regular physical exam. The nurse
knows which problem is frequently associated with Down Syndrome?
Congenital Heart Disease
When assessing a child with asthma the nurse should expect intercostal retractions during
inspiration
When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should
be minimized because it
stresses the suture line
A client with a productive cough has obtained a sputum specimen for culture as instructed. What
action is the best initial nursing action?
Administer the first dose of prescribed antibiotic therapy
A client is brought to the Emergency Department by ambulance in cardiac arrest with CPR in progress.
The client is intubated and receiving 100% O2 per ambu bag. The nurse determines the client is
cyanotic, cold, and diaphoretic. Which assessment is most important to obtain?
deep tendon reflexes
,After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops
pontine myselinolysis. Which intervention should the nurse implement first?
Reorientate client to his room
A male client with heart failure (HF) calls the clinic and reports he cannot put his shoes on because
they are too tight. Which additional information should the nurse obtain?
Has his weight changed in the last several days
An older adult with a long hx of COPD is admitted with progressive shortness of breath and a
persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the
nurse implement?
Apply a high flow venturi mask
A client with a hx of asthma and bronchitis arrives at the clinic with SOB, productive cough with
thickened tenacious mucous and the inability to walk up a flight of stairs without experiencing
breathlessness. Which action is important for the nurse to instruct the client about self care?
Increase the daily intake of oral fluids to to liquefy secretions
A cardiac catherization of a client with heart disease indicates the following blockages 95% LAD 99%
proximal circumflex and 95% proximal RCA. The client later asks the nurse "what does all that mean
for me"
3 main arteries have major blockages with only 1 to 5% of blood flow getting through to the heart
muscle
The nurse is caring for a client with a lower left pulmonary abscess which position should the nurse
instruct the client to maintain
left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or
drink without nausea and vomiting. Which finding should the nurse report to the healthcare provider
yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neuro
assessment every 4 hours. which assessment finding warrants immediate intervention by the nurse?
Increasing Anxiety
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to
promote burn healing. Which info should the nurse provide this client?
The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requests assistance to reposition. The
wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it
over the wound which intervention should the nurse implement next?
prepare the client to return to the operating room
A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117
mEq/L. Which nursing problem should the nurse include in this client's plan of care?
, Fluid volume excess
A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing
heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare
provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse
implement?
space the clients care to provide periods of rest
The nurse is teaching the client with glomerulonephritis about self care which dietary
recommendations should the nurse encourage the client to follow?
restrict intake by limiting meats and other high protein foods
An overweight, young adult male who was recently diagnosed with type 2 diabetes mellitus is
admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions
should the nurse implement?
- assess his skin temp and moisture
- document anxiety on the surgical checklist
-administer a PRN dose of regular insulin
A client with Cushings Syndrome is recovering from an elective laparoscopic procedure. Which
assessment finding warrants immediate intervention by the nurse?
irregular apical pulse
An adult client with primary Raynauds phenomenon develops pallor and then cyanosis of her finger.
After warming her hands the fingers turn red and the client reports a burning sensation. What action
should the nurse take?
secure a pulse oximeter to monitor the clients oxygen saturation
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His
right foot is cool with palpable pedal pulses. Lungs are coarse with diminished breath sounds. Vital
signs are temp 101, heart rate 128 bpm, respirations 28 bpm and BP 122/82 . Which intervention is
most important for the nurse to implement first?
Assess lower extremity circulation
The nurse is completing preoperative assessment of a client who is scheduled for a laparoscopic
cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare
provider?
The clients blood pressure is 184/88
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion.
Which additional finding warrants immediate action from the nurse?
hematocrit of 30%
Following surgical repair of the bladder a female client is being discharged from the hospital with an
indwelling catheter. Which instruction is most important for the nurse to provide to the client?
Keep the drainage bag lower than the level of the bladder
The nurse is giving preop instructions to a 14 yr old scheduled to correct a spinal curvature. Which
statement best demonstrates that learning has taken place?
I understand I will be in a body cast and I will show you hoy you taught me to turn
To take the vital signs of a 4 month old child which order will give the most accurate results?
Respiratory rate, heart rate, rectal temperature
AN otoscope exam of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging
and not movable. What action should the nurse take next?
Ask the child if he has has a cold, runny nose or any ear pain lately
Which restraint should be used for a toddler after a cleft palate repair?
elbow
What preoperative nursing intervention should be included in the plan of care for an infant with
pyloric stenosis?
Observe for projectile vomiting
A six month old returns from surgery with elbow restraints in place. What nursing intervention should
be included when caring for any restrained child?
remove restraints one at a time and provide range of motion exercise
A two year old with Down Syndrome is brought to the clinic for his regular physical exam. The nurse
knows which problem is frequently associated with Down Syndrome?
Congenital Heart Disease
When assessing a child with asthma the nurse should expect intercostal retractions during
inspiration
When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should
be minimized because it
stresses the suture line
A client with a productive cough has obtained a sputum specimen for culture as instructed. What
action is the best initial nursing action?
Administer the first dose of prescribed antibiotic therapy
A client is brought to the Emergency Department by ambulance in cardiac arrest with CPR in progress.
The client is intubated and receiving 100% O2 per ambu bag. The nurse determines the client is
cyanotic, cold, and diaphoretic. Which assessment is most important to obtain?
deep tendon reflexes
,After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops
pontine myselinolysis. Which intervention should the nurse implement first?
Reorientate client to his room
A male client with heart failure (HF) calls the clinic and reports he cannot put his shoes on because
they are too tight. Which additional information should the nurse obtain?
Has his weight changed in the last several days
An older adult with a long hx of COPD is admitted with progressive shortness of breath and a
persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the
nurse implement?
Apply a high flow venturi mask
A client with a hx of asthma and bronchitis arrives at the clinic with SOB, productive cough with
thickened tenacious mucous and the inability to walk up a flight of stairs without experiencing
breathlessness. Which action is important for the nurse to instruct the client about self care?
Increase the daily intake of oral fluids to to liquefy secretions
A cardiac catherization of a client with heart disease indicates the following blockages 95% LAD 99%
proximal circumflex and 95% proximal RCA. The client later asks the nurse "what does all that mean
for me"
3 main arteries have major blockages with only 1 to 5% of blood flow getting through to the heart
muscle
The nurse is caring for a client with a lower left pulmonary abscess which position should the nurse
instruct the client to maintain
left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or
drink without nausea and vomiting. Which finding should the nurse report to the healthcare provider
yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neuro
assessment every 4 hours. which assessment finding warrants immediate intervention by the nurse?
Increasing Anxiety
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to
promote burn healing. Which info should the nurse provide this client?
The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requests assistance to reposition. The
wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it
over the wound which intervention should the nurse implement next?
prepare the client to return to the operating room
A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117
mEq/L. Which nursing problem should the nurse include in this client's plan of care?
, Fluid volume excess
A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing
heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare
provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse
implement?
space the clients care to provide periods of rest
The nurse is teaching the client with glomerulonephritis about self care which dietary
recommendations should the nurse encourage the client to follow?
restrict intake by limiting meats and other high protein foods
An overweight, young adult male who was recently diagnosed with type 2 diabetes mellitus is
admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions
should the nurse implement?
- assess his skin temp and moisture
- document anxiety on the surgical checklist
-administer a PRN dose of regular insulin
A client with Cushings Syndrome is recovering from an elective laparoscopic procedure. Which
assessment finding warrants immediate intervention by the nurse?
irregular apical pulse
An adult client with primary Raynauds phenomenon develops pallor and then cyanosis of her finger.
After warming her hands the fingers turn red and the client reports a burning sensation. What action
should the nurse take?
secure a pulse oximeter to monitor the clients oxygen saturation
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His
right foot is cool with palpable pedal pulses. Lungs are coarse with diminished breath sounds. Vital
signs are temp 101, heart rate 128 bpm, respirations 28 bpm and BP 122/82 . Which intervention is
most important for the nurse to implement first?
Assess lower extremity circulation
The nurse is completing preoperative assessment of a client who is scheduled for a laparoscopic
cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare
provider?
The clients blood pressure is 184/88
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion.
Which additional finding warrants immediate action from the nurse?
hematocrit of 30%
Following surgical repair of the bladder a female client is being discharged from the hospital with an
indwelling catheter. Which instruction is most important for the nurse to provide to the client?
Keep the drainage bag lower than the level of the bladder
