HESI EXIT V2 CHAMBERLAIN COLLEGE
OF NURSING /A+ GRADE ASSURED
SUMMER 2024
• Patient: Pre-adolescent in skeletal Dunlop traction.
Situation: The nurse is caring for the child in traction.
Question: What is the appropriate nursing intervention?
• Ensure the child is in correct body alignment.
• Make 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 as needed. Answer: A
Feedback: Proper alignment helps in effective healing and prevents complications.
• Patient: Healthy child at a 2-year check-up.
Situation: The nurse is assessing the child.
Question: Which finding should be reported immediately to the healthcare provider?
• Significant variance in height and weight percentiles.
• Growth pattern appears to have slowed.
• Recumbent and standing height are different.
• Short-term weight changes are uneven. Answer: A
Feedback: Variations can indicate growth or developmental issues requiring further evaluation.
,• Patient: 2-year-old child holding breath during temper tantrums.
Situation: Parents report breath-holding during tantrums.
Question: 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 parents to ignore breath-holding as the child will resume breathing naturally.
• Instruct the parents on how to reason with the child about possible harmful effects. Answer: C
Feedback: Breath-holding typically resolves without intervention and does not cause long-term harm.
• Patient: Client in the emergency room.
Situation: The client describes chest pain.
Question: Which statement suggests 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."Answer: A
Feedback: This type of pain location is characteristic of angina, needing immediate attention.
• Patient: Client with possible organic brain disorder.
Situation: The nurse is assessing mental status.
Question: Which question best assesses recent memory function?
• "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) "Now continue tosubtract
7 from the new number."
• "I am going to say three words 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 of it?"Answer:
C
Feedback: This test evaluates the ability to recall recent information, critical in memory assessment.
• Patient: 6-month-old infant.
Situation: Planning care for the infant.
Question: What must the nurse provide to assist in developing trust?
• Food.
• Warmth.
• Security.
• Comfort. Answer: C
Feedback: Consistent and responsive care helps infants develop a sense of security and trust.
• Situation: Nurse receives an illegible medication order.
Question: Which statement best reflects assertive communication?
• "I cannot give this medication as it is written. I have no idea of what you mean."
• "Could you please clarify what you have written so I am sure I am reading it correctly?"
• "I am having difficulty reading your handwriting. It would save me time if you would be more careful."
• "Please print in the future so I do not have to spend extra time attempting to read your writing."
Answer: B
, Feedback: Clear communication ensures safe medication administration and patient safety.
• Situation: Teaching parents to reduce home risks.
Question: What is the most important consideration?
• Age and knowledge level of the parents.
• Proximity to emergency services.
• Number of children in the home.
• Age of children in the home. Answer: D
Feedback: Different ages pose different risks; safety measures should be age-appropriate.
• Patient: 35-year-old client with sickle cell crisis.
Situation: The client requests pain relief.
Question: What should the nurse do?
• Administer a placebo.
• Encourage increased fluid intake.
• Administer the prescribed analgesic.
• Recommend relaxation exercises for pain control. Answer: C
Feedback: Prompt pain management is crucial for clients in sickle cell crisis to alleviate pain and prevent
complications.
• Patient: Toddler with croup.
Situation: Nurse is monitoring the child.
Question: Which initial sign of croup requires immediate attention?
OF NURSING /A+ GRADE ASSURED
SUMMER 2024
• Patient: Pre-adolescent in skeletal Dunlop traction.
Situation: The nurse is caring for the child in traction.
Question: What is the appropriate nursing intervention?
• Ensure the child is in correct body alignment.
• Make 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 as needed. Answer: A
Feedback: Proper alignment helps in effective healing and prevents complications.
• Patient: Healthy child at a 2-year check-up.
Situation: The nurse is assessing the child.
Question: Which finding should be reported immediately to the healthcare provider?
• Significant variance in height and weight percentiles.
• Growth pattern appears to have slowed.
• Recumbent and standing height are different.
• Short-term weight changes are uneven. Answer: A
Feedback: Variations can indicate growth or developmental issues requiring further evaluation.
,• Patient: 2-year-old child holding breath during temper tantrums.
Situation: Parents report breath-holding during tantrums.
Question: 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 parents to ignore breath-holding as the child will resume breathing naturally.
• Instruct the parents on how to reason with the child about possible harmful effects. Answer: C
Feedback: Breath-holding typically resolves without intervention and does not cause long-term harm.
• Patient: Client in the emergency room.
Situation: The client describes chest pain.
Question: Which statement suggests 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."Answer: A
Feedback: This type of pain location is characteristic of angina, needing immediate attention.
• Patient: Client with possible organic brain disorder.
Situation: The nurse is assessing mental status.
Question: Which question best assesses recent memory function?
• "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) "Now continue tosubtract
7 from the new number."
• "I am going to say three words 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 of it?"Answer:
C
Feedback: This test evaluates the ability to recall recent information, critical in memory assessment.
• Patient: 6-month-old infant.
Situation: Planning care for the infant.
Question: What must the nurse provide to assist in developing trust?
• Food.
• Warmth.
• Security.
• Comfort. Answer: C
Feedback: Consistent and responsive care helps infants develop a sense of security and trust.
• Situation: Nurse receives an illegible medication order.
Question: Which statement best reflects assertive communication?
• "I cannot give this medication as it is written. I have no idea of what you mean."
• "Could you please clarify what you have written so I am sure I am reading it correctly?"
• "I am having difficulty reading your handwriting. It would save me time if you would be more careful."
• "Please print in the future so I do not have to spend extra time attempting to read your writing."
Answer: B
, Feedback: Clear communication ensures safe medication administration and patient safety.
• Situation: Teaching parents to reduce home risks.
Question: What is the most important consideration?
• Age and knowledge level of the parents.
• Proximity to emergency services.
• Number of children in the home.
• Age of children in the home. Answer: D
Feedback: Different ages pose different risks; safety measures should be age-appropriate.
• Patient: 35-year-old client with sickle cell crisis.
Situation: The client requests pain relief.
Question: What should the nurse do?
• Administer a placebo.
• Encourage increased fluid intake.
• Administer the prescribed analgesic.
• Recommend relaxation exercises for pain control. Answer: C
Feedback: Prompt pain management is crucial for clients in sickle cell crisis to alleviate pain and prevent
complications.
• Patient: Toddler with croup.
Situation: Nurse is monitoring the child.
Question: Which initial sign of croup requires immediate attention?
