HESI RN EXIT EXAM|Complete Questions with A+
Gaded Answers
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
Which client has the highest risk for developing skin cancer
a 65 year old fair skinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assessment is most
important for the nurse to obtain?
level of consciousness
A female client who was involved in an MVA is admitted with a fractured left
femur which is immobilized using a fracture traction splint in preparation for an
open reduction internal fixation (ORIF)
- verify pedal pulses using a doppler pulse device
-monitor left leg for pain, pallor, paresthesia,paralysis, pressure
-evaluate the application of the splint to the left leg
Lactulose has been prescribed for a client with advanced liver disease. Which
finding should the nurse use to evaluate the effectiveness of this treatment?
Gaded Answers
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
Which client has the highest risk for developing skin cancer
a 65 year old fair skinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assessment is most
important for the nurse to obtain?
level of consciousness
A female client who was involved in an MVA is admitted with a fractured left
femur which is immobilized using a fracture traction splint in preparation for an
open reduction internal fixation (ORIF)
- verify pedal pulses using a doppler pulse device
-monitor left leg for pain, pallor, paresthesia,paralysis, pressure
-evaluate the application of the splint to the left leg
Lactulose has been prescribed for a client with advanced liver disease. Which
finding should the nurse use to evaluate the effectiveness of this treatment?
