HESI PN EXIT EXAM V2 NEWEST 2024 ACTUAL
EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS |ALREADY GRADED A
• The nurse knows that which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4 year-old child?
• "I strap the infant car seat on the front seat to face backwards."
• "I place my infant in the middle of the living room floor on a blanket to play with my4
year old while I make supper in the kitchen."
• "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air
while the four year old naps on the sofa."
• "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen
while I make supper."
Answer: D
• Upon completing the admission documents, the nurse learns that the 87 year-old patient
does not have an advance directive. What action should the nurse take?
• Record the information on the chart
• Give information about advance directives
• Assume that this patient wishes a full code
• Refer this issue to the unit secretary
Answer: B
,• A nurse administers the influenza vaccine to a patient in a clinic. Within 15 minutes after the
immunization was given, the patient complains of itchy and watery eyes, increased anxiety, and
difficulty breathing. The nurse expects that the first action in the sequence of care for this
patient will be to
• Maintain the airway
• Administer epinephrine 1:1000 as ordered
• Monitor for hypotension with shock
• Administer diphenhydramine as ordered
Answer: B
• Which of these children at the site of a disaster at a child day care center would the triage
nurse put in the "treat last" category?
• An infant with intermittent bulging anterior fontanel between crying episodes
• A toddler with severe deep abrasions over 98% of the body
• A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
• A school-age child with singed eyebrows and hair on the arms
Answer: B
• When admitting a patient to an acute care facility, an identification bracelet is sent up withthe
admission form. In the event these do not match, the nurse's best action is to
• Change whichever item is incorrect to the correct information
• Use the bracelet and admission form until a replacement is supplied
• Notify the admissions office and wait to apply the bracelet
• Make a corrected identification bracelet for the patient
,Answer: C
• The nurse is having difficulty reading the health care provider's written order that was
written right before the shift change. What action should be taken?
• Leave the order for the oncoming staff to follow-up
• Contact the charge nurse for an interpretation
• Ask the pharmacy for assistance in the interpretation
• Call the provider for clarification
Answer: D
• An adult patient is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the nurse is to:
• check the carotid pulse
• deliver 5 abdominal thrusts
• give 2 rescue breaths
• open the patient's airway
Answer: D
• A patient has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that
800 ml has been infused after 4 hours. What is the priority nursing action?
• Ask the patient if there are any breathing problems
• Have the patient void as much as possible
• Check the vital signs
• Auscultate the lungs
, Answer: D
• Following change-of-shift report on an orthopedic unit, which patient should the nurse see
first?
• 16 year-old who had an open reduction of a fractured wrist 10 hours ago
• 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
• 72 year-old recovering from surgery after a hip replacement 2 hours ago
• 75 year-old who is in skin traction prior to planned hip pinning surgery.
Answer: C
• A nurse observes a family member administer a rectal suppository by having the patient lieon
the left side for the administration. The family member pushed the suppository until the finger
went up to the second knuckle. After 10 minutes the patient was told by the family member to
turn to the right side and the patient did this. What is the appropriate comment forthe nurse to
make?
• Why don't we now have the patient turn back to the left side.
• That was done correctly. Did you have any problems with the insertion?
• Let's check to see if the suppository is in far enough.
• Did you feel any stool in the intestinal tract?
Answer: B
• A patient with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died.
Which type of precautions is the appropriate type to use when performing postmortem care?
• airborne precautions
• droplet precautions
• contact precautions
• compromised host precautions
EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS |ALREADY GRADED A
• The nurse knows that which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4 year-old child?
• "I strap the infant car seat on the front seat to face backwards."
• "I place my infant in the middle of the living room floor on a blanket to play with my4
year old while I make supper in the kitchen."
• "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air
while the four year old naps on the sofa."
• "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen
while I make supper."
Answer: D
• Upon completing the admission documents, the nurse learns that the 87 year-old patient
does not have an advance directive. What action should the nurse take?
• Record the information on the chart
• Give information about advance directives
• Assume that this patient wishes a full code
• Refer this issue to the unit secretary
Answer: B
,• A nurse administers the influenza vaccine to a patient in a clinic. Within 15 minutes after the
immunization was given, the patient complains of itchy and watery eyes, increased anxiety, and
difficulty breathing. The nurse expects that the first action in the sequence of care for this
patient will be to
• Maintain the airway
• Administer epinephrine 1:1000 as ordered
• Monitor for hypotension with shock
• Administer diphenhydramine as ordered
Answer: B
• Which of these children at the site of a disaster at a child day care center would the triage
nurse put in the "treat last" category?
• An infant with intermittent bulging anterior fontanel between crying episodes
• A toddler with severe deep abrasions over 98% of the body
• A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
• A school-age child with singed eyebrows and hair on the arms
Answer: B
• When admitting a patient to an acute care facility, an identification bracelet is sent up withthe
admission form. In the event these do not match, the nurse's best action is to
• Change whichever item is incorrect to the correct information
• Use the bracelet and admission form until a replacement is supplied
• Notify the admissions office and wait to apply the bracelet
• Make a corrected identification bracelet for the patient
,Answer: C
• The nurse is having difficulty reading the health care provider's written order that was
written right before the shift change. What action should be taken?
• Leave the order for the oncoming staff to follow-up
• Contact the charge nurse for an interpretation
• Ask the pharmacy for assistance in the interpretation
• Call the provider for clarification
Answer: D
• An adult patient is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the nurse is to:
• check the carotid pulse
• deliver 5 abdominal thrusts
• give 2 rescue breaths
• open the patient's airway
Answer: D
• A patient has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that
800 ml has been infused after 4 hours. What is the priority nursing action?
• Ask the patient if there are any breathing problems
• Have the patient void as much as possible
• Check the vital signs
• Auscultate the lungs
, Answer: D
• Following change-of-shift report on an orthopedic unit, which patient should the nurse see
first?
• 16 year-old who had an open reduction of a fractured wrist 10 hours ago
• 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
• 72 year-old recovering from surgery after a hip replacement 2 hours ago
• 75 year-old who is in skin traction prior to planned hip pinning surgery.
Answer: C
• A nurse observes a family member administer a rectal suppository by having the patient lieon
the left side for the administration. The family member pushed the suppository until the finger
went up to the second knuckle. After 10 minutes the patient was told by the family member to
turn to the right side and the patient did this. What is the appropriate comment forthe nurse to
make?
• Why don't we now have the patient turn back to the left side.
• That was done correctly. Did you have any problems with the insertion?
• Let's check to see if the suppository is in far enough.
• Did you feel any stool in the intestinal tract?
Answer: B
• A patient with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died.
Which type of precautions is the appropriate type to use when performing postmortem care?
• airborne precautions
• droplet precautions
• contact precautions
• compromised host precautions
