HESI RN EXIT EXAM
rms in this set (160)
Original
1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour
after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart
rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding
to the surgeon. Which action should the nurse implement first?
d. Increase the infusion rate of Lactated Ringer's solution.
2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the
intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood
is measured in the collection chamber. Which intervention should the nurse implement?
a. Add sterile water to the suction control chamber.
3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg,
heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting
shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which
action should the nurse take first?
c. Begin supplemental oxygen.
4. A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation.
Based on the client's admitting diagnosis, which findings require immediate action by the nurse?
(Select all that apply)
Headache and tremors
Irregular heart rate
pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is
the best indicator of hydration that the nurse should report to the healthcare provider?
d. Skin tenting occurs when the client's forearm is pinched.
6. After an inservice about electronic health record (EHR) security and safeguarding client
information, the nurse observes a colleague going home with printed copies of client information in a
uniform pocket. Which action should the nurse take?
a. File a detailed incident report with the specific hiring facility.
7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease
implemented in a rural health clinic. Which outcome indicate the program is effective?
c. Clients who incurred disease complications promptly received rehabilitation.
8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen
at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased
shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement
first?
,d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate
investigation by the nurse?
When I get out of bed quickly, I feel a little dizzy."
10. An older adult male who is in his early 70's is admitted to the emergency department because of a
COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for
endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to
stop the procedure and provide the nurse a copy of the client's living will. Which action should the
nurse take?
b. Notify the healthcare provider of the client's wishes.
11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client
is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the
bedside commode. How should the nurse respond?
c. Advice the client to maintain bedrest so that safety can be ensured.
12. A nurse determines that more than 25% of the students at a middle school are overweight. The
nurse presents the information at the parent-teacher meeting. What action is most important for the
nurse to include in the meeting?
c. Distribute a shopping list of suggested healthy snack items.
13. After several months of chronic fatigue, morning stiffness, and join pain, a young adult is
diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which
education should the nurse provide the client with regard to taking prednisone?
c. If sequential doses are missed, notify the healthcare provider.
14. The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's
immediate attention?
c. An 18-year-old client with antisocial behavior who is being yelled at by other clients
15. The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?
b. Ear pain and fever.
16. A client arrives for an annual physical exam and complains of having calf pain. The client's health
history reveals peripheral atrial disease. Which question should the nurse ask the client about
expected finding related to chronic arterial symptoms?
b. Does the calf pain occur when walking short distances?
17. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which
client report is most important for them to explore further prior to the start of the procedure?
d. Experience facial swelling after eating crab.
, 18. The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the
mother reports that the child frequently scratches the lesions on the skin to the point of causing
bleeding. Which guideline is indicated for care of this child?
b. Apply baby lotion to the skin twice daily.
19. A new mother on the postpartum unit runs out of the room screaming that her newborn infant's
crib is empty and the baby is missing. What action should the nurse take first?
d. Match ID bands of all infants and mothers on the unit.
20. While providing a health history, a female client tells the clinic nurse that she frequently thinks
about hurting herself. Which question is most important for the nurse to ask?
c. "Have you thought about taking your life?"
21. A college student brings a dorm roommate to the campus clinic because the roommate has been
talking to someone who is not present. The client tells the nurse that the voices are saying, "kill, kill."
What question should the nurse ask the client next?
c. "Are you planning to obey the voices?"
22. The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly
diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of
care for this client?
d. The client's skin on the lower legs will be intact at the next clinical visit.
23. When conducting diet teaching for a client who was diagnosed with hypertension, which food
should the nurse encourage the client to eat? (select all that apply.)
a. . Fruits without sauce
c. Fresh or frozen vegetables without sauce.
24. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to
the nurse that the client is experiencing a therapeutic response to the phenytoin?
c. Absence of seizure activity for the duration of treatment.
25. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to
discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all
that apply)
a. Brings a heavy can close to body before lifting.
b. Locks knees while preparing food on the counter.
26. An older client is admitted to the hospital because of recurring transient ischemic attacks.
Neurological serial assessments for the past 24 hours were within normal limits. One day after
admission, the client suddenly becomes confused and combative indicating impaired mental status
(IMS). What intervention should the nurse implement first?
b. Reduce environmental stimuli.
27. The charge nurse in an extended care facility is organizing unit activities for the day. Which action
may be safely delegated to the practical nurse (PN)?
Establish blood pressure parameters for client monitoring
rms in this set (160)
Original
1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour
after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart
rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding
to the surgeon. Which action should the nurse implement first?
d. Increase the infusion rate of Lactated Ringer's solution.
2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the
intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood
is measured in the collection chamber. Which intervention should the nurse implement?
a. Add sterile water to the suction control chamber.
3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg,
heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting
shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which
action should the nurse take first?
c. Begin supplemental oxygen.
4. A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation.
Based on the client's admitting diagnosis, which findings require immediate action by the nurse?
(Select all that apply)
Headache and tremors
Irregular heart rate
pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is
the best indicator of hydration that the nurse should report to the healthcare provider?
d. Skin tenting occurs when the client's forearm is pinched.
6. After an inservice about electronic health record (EHR) security and safeguarding client
information, the nurse observes a colleague going home with printed copies of client information in a
uniform pocket. Which action should the nurse take?
a. File a detailed incident report with the specific hiring facility.
7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease
implemented in a rural health clinic. Which outcome indicate the program is effective?
c. Clients who incurred disease complications promptly received rehabilitation.
8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen
at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased
shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement
first?
,d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate
investigation by the nurse?
When I get out of bed quickly, I feel a little dizzy."
10. An older adult male who is in his early 70's is admitted to the emergency department because of a
COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for
endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to
stop the procedure and provide the nurse a copy of the client's living will. Which action should the
nurse take?
b. Notify the healthcare provider of the client's wishes.
11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client
is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the
bedside commode. How should the nurse respond?
c. Advice the client to maintain bedrest so that safety can be ensured.
12. A nurse determines that more than 25% of the students at a middle school are overweight. The
nurse presents the information at the parent-teacher meeting. What action is most important for the
nurse to include in the meeting?
c. Distribute a shopping list of suggested healthy snack items.
13. After several months of chronic fatigue, morning stiffness, and join pain, a young adult is
diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which
education should the nurse provide the client with regard to taking prednisone?
c. If sequential doses are missed, notify the healthcare provider.
14. The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's
immediate attention?
c. An 18-year-old client with antisocial behavior who is being yelled at by other clients
15. The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?
b. Ear pain and fever.
16. A client arrives for an annual physical exam and complains of having calf pain. The client's health
history reveals peripheral atrial disease. Which question should the nurse ask the client about
expected finding related to chronic arterial symptoms?
b. Does the calf pain occur when walking short distances?
17. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which
client report is most important for them to explore further prior to the start of the procedure?
d. Experience facial swelling after eating crab.
, 18. The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the
mother reports that the child frequently scratches the lesions on the skin to the point of causing
bleeding. Which guideline is indicated for care of this child?
b. Apply baby lotion to the skin twice daily.
19. A new mother on the postpartum unit runs out of the room screaming that her newborn infant's
crib is empty and the baby is missing. What action should the nurse take first?
d. Match ID bands of all infants and mothers on the unit.
20. While providing a health history, a female client tells the clinic nurse that she frequently thinks
about hurting herself. Which question is most important for the nurse to ask?
c. "Have you thought about taking your life?"
21. A college student brings a dorm roommate to the campus clinic because the roommate has been
talking to someone who is not present. The client tells the nurse that the voices are saying, "kill, kill."
What question should the nurse ask the client next?
c. "Are you planning to obey the voices?"
22. The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly
diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of
care for this client?
d. The client's skin on the lower legs will be intact at the next clinical visit.
23. When conducting diet teaching for a client who was diagnosed with hypertension, which food
should the nurse encourage the client to eat? (select all that apply.)
a. . Fruits without sauce
c. Fresh or frozen vegetables without sauce.
24. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to
the nurse that the client is experiencing a therapeutic response to the phenytoin?
c. Absence of seizure activity for the duration of treatment.
25. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to
discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all
that apply)
a. Brings a heavy can close to body before lifting.
b. Locks knees while preparing food on the counter.
26. An older client is admitted to the hospital because of recurring transient ischemic attacks.
Neurological serial assessments for the past 24 hours were within normal limits. One day after
admission, the client suddenly becomes confused and combative indicating impaired mental status
(IMS). What intervention should the nurse implement first?
b. Reduce environmental stimuli.
27. The charge nurse in an extended care facility is organizing unit activities for the day. Which action
may be safely delegated to the practical nurse (PN)?
Establish blood pressure parameters for client monitoring
