EXIT HESI - COMPREHENSIVE PN EXAM
A PRACTICE QUESTIONS
A nurse who has recently completed orientation is beginning work in the labor
and delivery unit for the first time. When making assignments, which client
should the charge nurse assign to this new nurse?
A multiparous client who is dilated 5 cm and 50% effaced
A client with human immunodeficiency virus (HIV) infection has white lesions in
the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is
prescribed as a swish and swallow. Which information is most important for the
nurse to provide the client?
Oral hygiene should be performed before the medication.
A client who is admitted with emphysema is having difficulty breathing. In which
position should the nurse place the client?
Sitting upright and forward with both arms supported on an over the bed table
A client with chronic renal insufficiency (CRI) is taking 25 mg of
hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today,
at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the
most likely cause of this client's potassium level?
The client's renal function has affected his potassium level.
A registered nurse (RN) delivers telehealth services to clients via electronic
communication. Which nursing action creates the greatest risk for professional
liability and has the potential for a malpractice lawsuit?
Sending medical records to health care providers via the Internet
Which pathophysiologic response supports the contraindication for opioids,
such as morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP
is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an
elevated ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an
elevated ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an
elevated ICP.
D
The greatest risk associated with opioids such as morphine (D) is respiratory
depression that causes an increase in Pco2, which increases ICP and masks the early
signs of intracranial bleeding in head injury. (A, B, and C) do not support the risks
associated with opioid use in a client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster
requiring implementation of the hospital's disaster plan. Specific facts about the
nature of this disaster are not yet known. Which instruction should the charge
nurse give to the other staff members at this time?
,A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received.
D
When faced with an impending disaster, hospital personnel may be alerted but should
continue with current client care assignments until further instructions are received (D).
Evacuation is typically a response of last resort that begins with clients who are most
able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming
casualties are anticipated. (C) is poor utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The
client's vital signs change suddenly, and the nurse determines that the client's
condition is worsening. The nurse is unsure of the client's resuscitative status
and needs to check the client's medical record for any advanced directives.
Which action should the nurse implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the
assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the
advanced directive.
C.Check the medical record for the advanced directive and then complete the
client assessment.
D.Call for the charge nurse to check the advanced directive while continuing to
assess the client.
D
Because the client's condition is worsening, the nurse should remain with the client and
continue the assessment while calling for help from the charge nurse to determine the
client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse
and cannot be delegated to the UAP. (C) is contraindicated.
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping
the nurse. Which task is important for the nurse to perform, rather than the UAP?
A.Remove the client's nail polish and dentures.
B.Assist the client to the restroom to void.
C.Obtain the client's height and weight.
D.Offer the client emotional support.
D
By using therapeutic techniques to offer support (D), the nurse can determine any client
concerns that need to be addressed. (A, B, and C) are all actions that can be performed
by the UAP under the supervision of the nurse.
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive
personnel (UAP) who usually works in labor and delivery and the newborn
nursery is assigned to work on the postoperative unit. Which client would be best
for the charge nurse to assign to this UAP?
, A.An adolescent who was readmitted to the hospital because of a postoperative
infection
B.A woman with a new colostomy who requires discharge teaching
C.A woman who had a hip replacement and may be transferred to the home care
unit
D.A man who had a cholecystectomy and currently has a nasogastric tube set to
intermittent suction
C
The charge nurse will be responsible for providing a report to the home care unit if the
transfer occurs (A). The client is infected and an employee who works on an OB unit
should be assigned to clean cases in case the employee is required to return to the OB
unit (B). This requires the skills of a registered nurse (RN) to do discharge teaching and
provide emotional support (D). This may require skills beyond the level of this UAP.
A male client is admitted for observation after being hit on the head with a
baseball bat. Six hours after admission, the client attempts to crawl out of bed
and asks the nurse why there are so many bugs in his bed. His vital signs are
stable, and the pulse oximeter reading is 98% on room air. Which intervention
should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed.
C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental
status (C). It is important to act early and quickly when symptoms of increased ICP
occur. Because his oxygen saturation is normal, the administration of oxygen (A) is not
the top priority. Vital signs should be monitored frequently (B), but the client's confusion
should be reported immediately. (D) is not a useful intervention.
The nurse is monitoring a client who is receiving bedside conscious sedation
with midazolam hydrochloride (Versed). In assessing the client, the nurse
determines that the client has slurred speech with diplopia. Based on this finding,
what action should the nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
D.Continue to monitor the client.
D
The desired level III in conscious sedation includes slurred speech, glazed eyes, and
marked diplopia. Because this is the desired outcome of the medication regimen, no
action is needed but continuing to monitor the client (D). The airway is open if the client
is able to talk (A). There are no signs of hypoglycemia (B). No reversal is necessary for
the benzodiazepine (Versed) without signs of oversedation, such as respiratory
depression (C).
A PRACTICE QUESTIONS
A nurse who has recently completed orientation is beginning work in the labor
and delivery unit for the first time. When making assignments, which client
should the charge nurse assign to this new nurse?
A multiparous client who is dilated 5 cm and 50% effaced
A client with human immunodeficiency virus (HIV) infection has white lesions in
the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is
prescribed as a swish and swallow. Which information is most important for the
nurse to provide the client?
Oral hygiene should be performed before the medication.
A client who is admitted with emphysema is having difficulty breathing. In which
position should the nurse place the client?
Sitting upright and forward with both arms supported on an over the bed table
A client with chronic renal insufficiency (CRI) is taking 25 mg of
hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today,
at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the
most likely cause of this client's potassium level?
The client's renal function has affected his potassium level.
A registered nurse (RN) delivers telehealth services to clients via electronic
communication. Which nursing action creates the greatest risk for professional
liability and has the potential for a malpractice lawsuit?
Sending medical records to health care providers via the Internet
Which pathophysiologic response supports the contraindication for opioids,
such as morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP
is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an
elevated ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an
elevated ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an
elevated ICP.
D
The greatest risk associated with opioids such as morphine (D) is respiratory
depression that causes an increase in Pco2, which increases ICP and masks the early
signs of intracranial bleeding in head injury. (A, B, and C) do not support the risks
associated with opioid use in a client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster
requiring implementation of the hospital's disaster plan. Specific facts about the
nature of this disaster are not yet known. Which instruction should the charge
nurse give to the other staff members at this time?
,A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received.
D
When faced with an impending disaster, hospital personnel may be alerted but should
continue with current client care assignments until further instructions are received (D).
Evacuation is typically a response of last resort that begins with clients who are most
able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming
casualties are anticipated. (C) is poor utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The
client's vital signs change suddenly, and the nurse determines that the client's
condition is worsening. The nurse is unsure of the client's resuscitative status
and needs to check the client's medical record for any advanced directives.
Which action should the nurse implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the
assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the
advanced directive.
C.Check the medical record for the advanced directive and then complete the
client assessment.
D.Call for the charge nurse to check the advanced directive while continuing to
assess the client.
D
Because the client's condition is worsening, the nurse should remain with the client and
continue the assessment while calling for help from the charge nurse to determine the
client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse
and cannot be delegated to the UAP. (C) is contraindicated.
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping
the nurse. Which task is important for the nurse to perform, rather than the UAP?
A.Remove the client's nail polish and dentures.
B.Assist the client to the restroom to void.
C.Obtain the client's height and weight.
D.Offer the client emotional support.
D
By using therapeutic techniques to offer support (D), the nurse can determine any client
concerns that need to be addressed. (A, B, and C) are all actions that can be performed
by the UAP under the supervision of the nurse.
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive
personnel (UAP) who usually works in labor and delivery and the newborn
nursery is assigned to work on the postoperative unit. Which client would be best
for the charge nurse to assign to this UAP?
, A.An adolescent who was readmitted to the hospital because of a postoperative
infection
B.A woman with a new colostomy who requires discharge teaching
C.A woman who had a hip replacement and may be transferred to the home care
unit
D.A man who had a cholecystectomy and currently has a nasogastric tube set to
intermittent suction
C
The charge nurse will be responsible for providing a report to the home care unit if the
transfer occurs (A). The client is infected and an employee who works on an OB unit
should be assigned to clean cases in case the employee is required to return to the OB
unit (B). This requires the skills of a registered nurse (RN) to do discharge teaching and
provide emotional support (D). This may require skills beyond the level of this UAP.
A male client is admitted for observation after being hit on the head with a
baseball bat. Six hours after admission, the client attempts to crawl out of bed
and asks the nurse why there are so many bugs in his bed. His vital signs are
stable, and the pulse oximeter reading is 98% on room air. Which intervention
should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed.
C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental
status (C). It is important to act early and quickly when symptoms of increased ICP
occur. Because his oxygen saturation is normal, the administration of oxygen (A) is not
the top priority. Vital signs should be monitored frequently (B), but the client's confusion
should be reported immediately. (D) is not a useful intervention.
The nurse is monitoring a client who is receiving bedside conscious sedation
with midazolam hydrochloride (Versed). In assessing the client, the nurse
determines that the client has slurred speech with diplopia. Based on this finding,
what action should the nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
C.Administer flumazenil (Romazicon).
D.Continue to monitor the client.
D
The desired level III in conscious sedation includes slurred speech, glazed eyes, and
marked diplopia. Because this is the desired outcome of the medication regimen, no
action is needed but continuing to monitor the client (D). The airway is open if the client
is able to talk (A). There are no signs of hypoglycemia (B). No reversal is necessary for
the benzodiazepine (Versed) without signs of oversedation, such as respiratory
depression (C).
