HESI EXIT NGN, HESI RN Exit Exam 2024 QUESTIONS AND CORRECT DETAILED ANSWERS

HESI EXIT NGN, HESI RN Exit Exam 2024 QUESTIONS AND CORRECT DETAILED ANSWERS The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding? A. An audible voice when client is trying to communicate B. High pressure alarm sounds when client is coughing C. Restrained and restless with a low volume alarm sounding D. Diminished breath sounds in the right posterior base - ANSWER C. Restrained and restless with a low volume alarm sounding A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull gnawing pain that is relieved when he eats. Which is the best response by the nurse? A. Instruct the client that these mild symptoms can generally be controlled with changes in his diet B. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms C. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer D. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food - ANSWER C. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendations for hypertension? A. Grilled steak, baked potato with sour cream, green beans, coffee, and raisin cream pie B. Baked pork chops, applesauce, corn on the cob, 1% milk, and key-lime pie C. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie D. Beef stir fry, fried rice, egg drop soup, diet soda, and pumpkin pie - ANSWER B. Baked pork chops, applesauce, corn on the cob, 1% milk, and key-lime pie A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report to the healthcare provider? A. Volume of each voiding is more than 300mL B. Serum potassium that is elevated C. Relief of flank pain that radiated into the groin D. Hematuria that is beginning to turn pink - ANSWER D. Hematuria that is beginning to turn pink Three days after initiating parenteral fluids for a newborn with a ventricular septal defect (VSD), the nurse assesses an increase in heart rate and blood pressure. Which intervention is most important for the nurse to implement? A. View the graph of daily weights B. Restrict intake of oral fluids C. Assess bilateral lung sounds D. Decrease IV flow rate - ANSWER B. Restrict intake of oral fluids During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care? A. History of suicide attempts B. Feelings of disorientation C. Undiagnosed social anxiety symptoms (SAD) D. Family history of schizophrenia - ANSWER A. History of suicide attempts The healthcare provider prescribes penicillin G benzathine 2,400,000 units intramuscularly for a client who has a postoperative wound infection. The prefilled syringe is labeled, penicillin G benzathine 1,200,000 units/2mL. How many mL should the nurse administer to this client? - ANSWER 4mL A client who experienced a cerebrovascular accident (CVA) is aphasic and has left sided paralysis. Which nurse should be responsible for coordinating the progression of this client's care? A. Nurse case manager B. Adult nurse practitioner C. Neurology unit supervisor D. Risk management nurse - ANSWER B. Adult nurse practitioner A client who is admitted with complications related to hypopituitarism is diaphoretic and hypotensive. Which assessment finding warrants immediate intervention by the nurse? - ANSWER Lethargy A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to maintaining physical safety, which short-term goal should the nurse include in the plan of care? A. Sleeps at least 6 hours per night B. Consumes 3 meals and 1500 mL of fluid per day C. Engages in one client to client interaction daily D. Attends one group activity per day - ANSWER D. Attends one group activity per day A 7-year old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider? A. Shift intake of 640mL IV fluids plus 30mL PO ice chips B. Serum pH of 7.45 C. Gastric output of 100 mL in the last 8 hours D. Serum potassium of 3.0 mg/dL - ANSWER D. Serum potassium of 3.0 mg/dL A male client approaches the nurse with an angry expression on his face and raises his voice, saying "My roommate is the most selfish, self-centered, angry person I have ever met and if he loses his temper one more time with me, I am going to punch him out!" The nurse recognizes that the client is using which defense mechanism? A. Splitting B. Projection C. Rationalization D. Denial - ANSWER B. Projection The nurse is teaching the client about home care after surgery for an ileal conduit placement. When reviewing the information, which statement should the nurse recognize as needing additional education? A. report presence of mucus in the urine B. Empty pouch when it is half full C. Look at the stoma when replacing appliance D. Anticipate shrinking of the stoma - ANSWER B. Empty pouch when it is half full A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse? A. One inch bleeding laceration on the chin of crying 5 year old B. Low grade fever, headache and malaise for the past 72 hours C. Chest discomfort one hour after consuming a large, spicy meal D. Unable to bear weight on the left food, with swelling and bruising - ANSWER C. Chest discomfort one hour after consuming a large, spicy meal When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm, but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement? A. Analyze the cardiac rhythm in another lead B. Obtain a 12-lead electrocardiogram C. Observe for swelling at the fracture site D. Begin chest compressions at 100/minute - ANSWER D. Begin chest compressions at 100/minute The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately? A. Change the dressing using a compression bandage B. Test the fluid on the dressing for glucose C. Document the findings in the electronic medical record D. Mark the drainage area with a pen and continue to monitor - ANSWER B. Test the fluid on the dressing for glucose After administering a 12 ounce can of nutritional supplement, 3 teaspoons of medication, and 120 mL of water, the nurse should document the client's fluid intake as how many mL? - ANSWER 495 The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicates the client understands how to maintain balance safely? (Select all that apply) A. Brings a heavy can close to body before lifting B. Leans forward to pull on a pan from a high shelf C. Locks knees while preparing food on the counter D. Bends from the waist to pick trash off the floor E. Widens stance while working near the sink - ANSWER C. Locks knees while preparing food on the counter D. Bends from the waist to pick trash off the floor A client with rheumatoid arthritis (RA) starts a new prescription for etanercept subcutaneously once weekly. The nurse should emphasize the importance of reporting which problem to the healthcare provider? A. Joint stiffness B. Persistent fever C. Headache D. Increased hunger and thirst - ANSWER A. Joint stiffness A client with multiple burn injuries is being treated in the burn trauma unit just hours after the injuries occurred. The healthcare provider instructs the nurse to avoid auto contamination when performing dressing changes. Which intervention is most important for the nurse to implement? A. Dress each wound separately B. Assign equipment to this one client C. Utilize reverse isolation protocol D. Use gown, mask, and gloves with dressing changes - ANSWER D. Use gown, mask, and gloves with dressing changes A client with chronic kidney disease has an arteriovenous fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent? A. Assessment of a bruit on the left forearm B. Auscultation of a thrill on the left forearm C. The left radial pulse is 2+ bounding. - ANSWER B. Auscultation of a thrill on the left forearm A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complains of pain at the right groin insertion site. What action should the nurse implement? A. Check femoral site for hematoma formation B. Stimulate the client to take deep breaths C. Evaluate the integrity of the IV insertion site D. Assess distal lower extremity capillary refill - ANSWER B. Stimulate the client to take deep breaths The nurse is caring for client with flail chest secondary to 3 right rib fractures after sustaining a fall from a ladder. The client is anxious, but stable with an oxygen saturation of (SpO2) 93%. Which action should the nurse take? A. Splint affected side B. Insert nasal airway C. Coach through taking deep breaths D. Apply a non-rebreather mask - ANSWER A. Splint affected side The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three days ago. The client plans to live with a family member. Which actions should the nurse implement? (Select all that apply) A. Teach care of ostomy to care provider B. Assess the client for self care ability C. Provide pain medication instructions D. Request a home safety inspection E. Call home care agency to set up oxygen - ANSWER A. Teach care of ostomy to care provider B. Assess the client for self care ability C. Provide pain medication instructions The nurse is caring for a client with the sexually transmitted infection (STI) chlamydia. The client reports having sex with someone who had many partners. Which response should the nurse provide? A. Inform that follow-up may end after the treatment is finished B. Reassure that complications will not occur if the infection is treated C. Notify that persons with STIs are reported to local health departments D. Explain how the infection is transmitted and the health risks involved - ANSWER A. Inform that follow-up may end after the treatment is finished. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? A. Monitor the amount of drainage from the client's incision B. Observe both lower extremities for redness and swelling C. Evaluate the client's ability to use an incentive spirometer D. Palpate all peripheral pulse points for volume and strength - ANSWER B. Observe both lower extremities for redness and swelling The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first? A. Review medical records to obtain pain tolerance expectations B. Attempt to obtain a self-report of pain level from the client C. Provide the first medication prescribed for pain management D. Wait until the client is awake before providing pain management - ANSWER B. Attempt to obtain a self-report of pain level from the client The nurse assessing a client who reports falling 2 days ago and has a history of gouty arthritis that is controlled with allopurinol. The client states the left knee is swollen and extremely pain to touch. Which instruction should the nurse include in the discharge teaching? A. Decrease consumption of red meat and most seafood B. Substitute natural fruit juices for carbonated drinks C. Limit use of mobility equipment to avoid muscle atrophy D. Use electric heating pad when pain is at its worse - ANSWER A. Decrease consumption of red meat and most seafood The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3 year old son for wetting his pants. What initial action should the nurse take? A. Provide disposable training pants while calming the mother B. Refer the mother to a community parent education program C. Inform the mother that toilet training is slower for boys D. Suggest that the mother consult a pediatric nephrologist - ANSWER C. Inform the mother that toilet training is slower for boys The nurse is caring for a client with heart failure. Which method is used in computing the cardiac index to measure how the client's heart is functioning? A. Mean arterial pressure minus right atrial pressure B. Cardiac output divided by body surface area C. Stroke volume divided by end diastolic volume D. Stroke volume multiplied by heart rate - ANSWER B. Cardiac output divided by body surface area Two days prior to discharge from the rehabilitation facility, the nurse is teaching a client who is recovering from Guillain-Barre syndrome about home care. Which actions should the nurse include when providing discharge teaching to the client and spouse? (Select all that apply) A. Review safe transfer strategies B. Develop a nutritional plan C. Help identify community support D. Initiate a rigorous exercise routine E. Provide cooking instructions - ANSWER A. Review safe transfer strategies B. Develop a nutritional plan C. Help identify community support A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take? A. Place the nasal swab specimen for COVID-19 directly into a biohazard bag B. Move the client to a private room, keep the door closed, and initiate droplet precautions. C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. - ANSWER A. Place the nasal swab specimen for COVID-19 directly into a biohazard bag An older adult client with systemic inflammatory response syndrome (SIRS) has a temperature of 101.8F, heart rate of 110 beats/minute, and respiratory rate of 24 breaths/minute. Which additional finding is most important to report to the healthcare provider? A. Capillary glucose reading of 110 mg/dL B. Serum creatinine of 2.0 mg/dL C. Blood pressure of 130/88 mmHg D. Hemoglobin of 12 g/dL - ANSWER B. Serum creatinine of 2.0 mg/dL The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP? A. Evaluate a client's mobility progress toward the plan of care B. Assess for side effects of administered pain medications C. Turn and reposition a client with a total hip replacement D. Monitor an intravenous infusion rate on an established schedule - ANSWER C. Turn and reposition a client with a total hip replacement After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3 mg/dL. Which action should the nurse implement? A. Evaluate the client's serum BUN level B. Initiate the urine collection as prescribed C. Notify the healthcare provider of the results D. Assess the client for signs of hypokalemia - ANSWER C. Notify the healthcare provider of the results The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? A. The client's skin on the lower legs will be intact at the next clinic visit B. The client will express acceptance of their newly diagnosed health status C. The client's blood pressure readings will be less than 160/90 mmHg D. The nurse will encourage the client to walk thirty minutes every day - ANSWER C. The client's blood pressure readings will be less than 160/90 mmHg The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? A. Increase activity and exercise gradually, as tolerated B. Limit intake of fatty foods for one month after surgery C. Avoid crowds for first two months after surgery D. Notify the healthcare provider if edema occurs - ANSWER C. Avoid crowds for first two months after surgery What might the nurse suggest to a client with fibrocystic breasts in an attempt to help relieve her symptoms? A. "Eliminate caffeine from your diet" B. "Avoid vigorous physical exercise immediately after your menstrual periods" C. "Eat a low-carbohydrate, high-protein diet" D. "Increase high-calcium foods in your diet" - ANSWER D. "Increase high-calcium foods in your diet" When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? (Select all that apply) A. Cheese B. Tea C. Lentils D. Whole grain breads E. Potato soup - ANSWER B. Tea C. Lentils E. Potato soup The mother of a 2 day old infant girl expresses concern about a "flea bite" type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer? A. This is a common newborn rash that will resolve after several days B. The rash is due to distended oil glands that will resolve in a few weeks C. The healthcare provider is being notified about the rash D. This rash is characteristic of a medication reaction - ANSWER A. This is a common newborn rash that will resolve after several days A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care? A. Risk for ineffective self-health management related to deficient knowledge B. Ineffective coping related to personal vulnerability C. Risk for injury related to vertigo D. Anxiety related to disruption of lifestyle - ANSWER C. Risk for injury related to vertigo. The nurse should withhold which medication if the client's serum potassium level is 6.2 mEq/L? A. Metolazone B. Furosemide C. Spironolactone D. Hydrochlorothiazide - ANSWER C. Spironolactone A female client presents in the emergency department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? A. Has she taken a bath since the rape occurred? B. Is the place where she lives a safe place? C. Does she know the person who raped her? D. Did she report the rape to the police department? - ANSWER A. Has she taken a bath since the rape occurred? The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? - ANSWER pt who develop disease complications promptly received rehabilitation The nurse has received funding to design a health promotion project for African American women who are at risk for developing breast cancer. Which resource is most important in designing this program? - ANSWER participation of community leaders in planning the program