HESI EXIT EXAM V4 ACTUAL EXAM ALL QUESTIONS AN
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+
• The nurse is caring for a pre-adolescent client in skeletal Dunlop traction.
Whichnursing intervention is appropriate for this child?
• Make certain the child is maintained in correct body alignment.
• Be sure the traction weights touch the end of the bed.
• Adjust the head and foot of the bed for the child's comfort
• Release the traction for 15-20 minutes every 6 hours PRN.
The correct answer is A: Make certain the child is maintained in correct body alignment.
• The nurse is assessing a healthy child at the 2 year check up. Which of the
followingshould the nurse report immediately to the health care provider?
• Height and weight percentiles vary widely
• Growth pattern appears to have slowed
• Recumbent and standing height are different
• Short term weight changes are uneven
The correct answer is A: Height and weight percentiles vary widely
• The parents of a 2 year-old child report that he has been holding his breath
wheneverhe has temper tantrums. What is the best action by the nurse?
• Teach the parents how to perform cardiopulmonary resuscitation
• Recommend that the parents give in when he holds his breath to prevent anoxia
• Advise the parents to ignore breath holding because breathing will begin as a reflex
• Instruct the parents on how to reason with the child about possible harmful effects
The correct answer is C: Advise the parents to ignore breath holding because
breathingwill begin as a reflex
• The nurse is assessing a client in the emergency room. Which statement suggests
thatthe problem is acute angina?
• "My pain is deep in my chest behind my sternum."
• "When I sit up the pain gets worse."
• "As I take a deep breath the pain gets worse."
• "The pain is right here in my stomach area."
The correct answer is A: "My pain is deep in my chest behind my sternum."
,.
• The nurse is assessing the mental status of a client admitted with possible organic
braindisorder. Which of these questions will best assess the function of the client's recent
memory?
• "Name the year." "What season is this?" (pause for answer after each question)
• "Subtract 7 from 100 and then subtract 7 from that." (pause for answer)
"Nowcontinue to subtract 7 from the new number."
• "I am going to say the names of three things and I want you to repeat them after
me:blue, ball, pen."
• "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose
ofit?"
The correct answer is C: "I am going to say the names of three things and I want you to
repeat them after me: blue, ball, pen."
• In planning care for a 6 month-old infant, what must the nurse provide to assist in
thedevelopment of trust?
• Food
• Warmth
• Security
• Comfort
The correct answer is C: Security
• A nurse has just received a medication order which is not legible. Which statement
bestreflects assertive communication?
• "I cannot give this medication as it is written. I have no idea of what you mean."
• "Would you please clarify what you have written so I am sure I am reading
itcorrectly?"
• "I am having difficulty reading your handwriting. It would save me time if you
wouldbe more careful."
• "Please print in the future so I do not have to spend extra time attempting to read
yourwriting."
The correct answer is B) "Would you please clarify what you have written so I am sure I
am
reading it correctly?"
• What is the most important consideration when teaching parents how to reduce risks
inthe home?
• Age and knowledge level of the parents
,• Proximity to emergency services
• Number of children in the home
• Age of children in the home
The correct answer is D: Age of children in the home
• A 35 year-old client with sickle cell crisis is talking on the telephone but stops as
thenurse enters the room to request something for pain. The nurse should
• Administer a placebo
• Encourage increased fluid intake
• Administer the prescribed analgesia
• Recommend relaxation exercises for pain control
The correct answer is C: Administer the prescribed analgesia
• While caring for a toddler with croup, which initial sign of croup requires the
nurse's immediate attention?
• Respiratory rate of 42
• Lethargy for the past hour
• Apical pulse of 54
• Coughing up copious secretions
The correct answer is A: Respiratory rate of 30
• A client is admitted with low T3 and T4 levels and an elevated TSH level. On
initialassessment, the nurse would anticipate which of the following assessment
findings?
• Lethargy
• Heat intolerance
• Diarrhea
• Skin eruptions
The correct answer is A: Lethargy
• The emergency room nurse admits a child who experienced a seizure at school.
Thefather comments that this is the first occurrence, and denies any family history of
epilepsy. What is the best response by the nurse?
• "Do not worry. Epilepsy can be treated with medications."
• "The seizure may or may not mean your child has epilepsy."
• "Since this was the first convulsion, it may not happen again."
• "Long term treatment will prevent future seizures."
, The correct answer is B: "The seizure may or may not mean your child has epilepsy."
• Alcohol and drug abuse impairs judgment and increases risk taking behavior.
Whatnursing diagnosis best applies?
• Risk for injury
• Risk for knowledge deficit
• Altered thought process
• Disturbance in self-esteem
The correct answer is A: Risk for injury
• The nurse is caring for a 10 month-old infant who is has oxygen via mask. It
isimportant for the nurse to maintain patency of which of these areas?
• Mouth
• Nasal passages
• Back of throat
• Bronchials
The correct answer is B: Nasal passages
• The nurse is providing instructions for a client with pneumonia. What is the
mostimportant information to convey to the client?
• "Take at least 2 weeks off from work."
• "You will need another chest x-ray in 6 weeks."
• "Take your temperature every day."
• "Complete all of the antibiotic even if your findings decrease."
The correct answer is D: "Complete all of the antibiotic even if your findings decrease."
• When counseling a 6 year old who is experiencing enuresis, what must the
nurseunderstand about the pathophysiological basis of this disorder?
• Has no clear etiology
• May be associated with sleep phobia
• Has a definite genetic link
• Is a sign of willful misbehavior
The correct answer is A: Has no clear etiology
• The nurse is discussing negativism with the parents of a 30 month-old child.
How should the nurse tell the parents to best respond to this behavior?
• Reprimand the child and give a 15 minute "time out"
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+
• The nurse is caring for a pre-adolescent client in skeletal Dunlop traction.
Whichnursing intervention is appropriate for this child?
• Make certain the child is maintained in correct body alignment.
• Be sure the traction weights touch the end of the bed.
• Adjust the head and foot of the bed for the child's comfort
• Release the traction for 15-20 minutes every 6 hours PRN.
The correct answer is A: Make certain the child is maintained in correct body alignment.
• The nurse is assessing a healthy child at the 2 year check up. Which of the
followingshould the nurse report immediately to the health care provider?
• Height and weight percentiles vary widely
• Growth pattern appears to have slowed
• Recumbent and standing height are different
• Short term weight changes are uneven
The correct answer is A: Height and weight percentiles vary widely
• The parents of a 2 year-old child report that he has been holding his breath
wheneverhe has temper tantrums. What is the best action by the nurse?
• Teach the parents how to perform cardiopulmonary resuscitation
• Recommend that the parents give in when he holds his breath to prevent anoxia
• Advise the parents to ignore breath holding because breathing will begin as a reflex
• Instruct the parents on how to reason with the child about possible harmful effects
The correct answer is C: Advise the parents to ignore breath holding because
breathingwill begin as a reflex
• The nurse is assessing a client in the emergency room. Which statement suggests
thatthe problem is acute angina?
• "My pain is deep in my chest behind my sternum."
• "When I sit up the pain gets worse."
• "As I take a deep breath the pain gets worse."
• "The pain is right here in my stomach area."
The correct answer is A: "My pain is deep in my chest behind my sternum."
,.
• The nurse is assessing the mental status of a client admitted with possible organic
braindisorder. Which of these questions will best assess the function of the client's recent
memory?
• "Name the year." "What season is this?" (pause for answer after each question)
• "Subtract 7 from 100 and then subtract 7 from that." (pause for answer)
"Nowcontinue to subtract 7 from the new number."
• "I am going to say the names of three things and I want you to repeat them after
me:blue, ball, pen."
• "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose
ofit?"
The correct answer is C: "I am going to say the names of three things and I want you to
repeat them after me: blue, ball, pen."
• In planning care for a 6 month-old infant, what must the nurse provide to assist in
thedevelopment of trust?
• Food
• Warmth
• Security
• Comfort
The correct answer is C: Security
• A nurse has just received a medication order which is not legible. Which statement
bestreflects assertive communication?
• "I cannot give this medication as it is written. I have no idea of what you mean."
• "Would you please clarify what you have written so I am sure I am reading
itcorrectly?"
• "I am having difficulty reading your handwriting. It would save me time if you
wouldbe more careful."
• "Please print in the future so I do not have to spend extra time attempting to read
yourwriting."
The correct answer is B) "Would you please clarify what you have written so I am sure I
am
reading it correctly?"
• What is the most important consideration when teaching parents how to reduce risks
inthe home?
• Age and knowledge level of the parents
,• Proximity to emergency services
• Number of children in the home
• Age of children in the home
The correct answer is D: Age of children in the home
• A 35 year-old client with sickle cell crisis is talking on the telephone but stops as
thenurse enters the room to request something for pain. The nurse should
• Administer a placebo
• Encourage increased fluid intake
• Administer the prescribed analgesia
• Recommend relaxation exercises for pain control
The correct answer is C: Administer the prescribed analgesia
• While caring for a toddler with croup, which initial sign of croup requires the
nurse's immediate attention?
• Respiratory rate of 42
• Lethargy for the past hour
• Apical pulse of 54
• Coughing up copious secretions
The correct answer is A: Respiratory rate of 30
• A client is admitted with low T3 and T4 levels and an elevated TSH level. On
initialassessment, the nurse would anticipate which of the following assessment
findings?
• Lethargy
• Heat intolerance
• Diarrhea
• Skin eruptions
The correct answer is A: Lethargy
• The emergency room nurse admits a child who experienced a seizure at school.
Thefather comments that this is the first occurrence, and denies any family history of
epilepsy. What is the best response by the nurse?
• "Do not worry. Epilepsy can be treated with medications."
• "The seizure may or may not mean your child has epilepsy."
• "Since this was the first convulsion, it may not happen again."
• "Long term treatment will prevent future seizures."
, The correct answer is B: "The seizure may or may not mean your child has epilepsy."
• Alcohol and drug abuse impairs judgment and increases risk taking behavior.
Whatnursing diagnosis best applies?
• Risk for injury
• Risk for knowledge deficit
• Altered thought process
• Disturbance in self-esteem
The correct answer is A: Risk for injury
• The nurse is caring for a 10 month-old infant who is has oxygen via mask. It
isimportant for the nurse to maintain patency of which of these areas?
• Mouth
• Nasal passages
• Back of throat
• Bronchials
The correct answer is B: Nasal passages
• The nurse is providing instructions for a client with pneumonia. What is the
mostimportant information to convey to the client?
• "Take at least 2 weeks off from work."
• "You will need another chest x-ray in 6 weeks."
• "Take your temperature every day."
• "Complete all of the antibiotic even if your findings decrease."
The correct answer is D: "Complete all of the antibiotic even if your findings decrease."
• When counseling a 6 year old who is experiencing enuresis, what must the
nurseunderstand about the pathophysiological basis of this disorder?
• Has no clear etiology
• May be associated with sleep phobia
• Has a definite genetic link
• Is a sign of willful misbehavior
The correct answer is A: Has no clear etiology
• The nurse is discussing negativism with the parents of a 30 month-old child.
How should the nurse tell the parents to best respond to this behavior?
• Reprimand the child and give a 15 minute "time out"
