HESI PN EXIT EXAM EXAM COMPLETE EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta)
for the past 12 days. Which assessment finding requires immediate follow-up?
a- Describes life without purpose
b- Complains of nausea and loss of appetite
c- States is often fatigued and drowsy
d- Exhibits an increase in sweating. - ANSWER: Describes life without purpose
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer.
Her Papanicolau (Pap) smear results are negative. What information should the
nurse include in the client‟s teaching plan?
a- Further evaluation involving surgery may be needed
b- A pelvic exam is also needed before cancer is ruled out
c- Pap smear evaluation should be continued every six month
d- One additional negative pap smear in six months is needed. - ANSWER: Further
evaluation involving surgery may be need
A client who recently underwear a tracheostomy is being prepared for discharge to
home. Which instructions is most important for the nurse to include in the discharge
plan?
a- Explain how to use communication tools.
b- Teach tracheal suctioning techniques
c- Encourage self-care and independence.
d- Demonstrate how to clean tracheostomy site. - ANSWER: Teach tracheal
suctioning techniques
. In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client‟s
respiratory rate is 14 breaths / minute. What action should the nurse implement?
a- Encourage the client to take deep breaths
b- Remove the mask to deflate the bag
c- Increase the liter flow of oxygen
d- Document the assessment data - ANSWER: Document the assessment data
Rational: Reservoir bag should not deflate completely during inspiration and the
clients respiratory rate is WNL
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What action should the nurse take first?
a- Give the client 4 ounces of orange juice
b- Call 911 to summon emergency assistance
c- Check the client for lacerations or fractures
,d- Asses clients blood sugar level - ANSWER: Check the client for lacerations or
fractures
* Rationale: After the client falls, the nurse should immediately assess for the
possibility of injuries and provide first aid as needed
. At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at 0400 because she
wanted to avoid getting a headache. Which action should the nurse take first?
a- Ensure preoperative lab results are available
b- Start prescribed IV with lactated Ringer‟s
c- Inform the anesthesia care provider
d- Contact the client‟s obstetrician. - ANSWER: Inform the anesthesia care provider
*Rationale: Surgical preoperative instruction includes NPO after midnight the day of
surgery to decrease the risk of aspiration should vomiting occur during anesthesia.
While it is possible the C-section will be done on schedule or rescheduled for later in
the day, the anesthesia provider should be notified first.
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first?
a- Side the stethoscope across the sternum.
b- Move the stethoscope to the mitral site
c- Listen with the bell at the same location
d- Observe the cardiac telemetry monitor - ANSWER: Listen with the bell at the same
location
*Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds
such as S3 and S4. The nurse listens at the same site using the diaphragm the
diaphragm and bell before moving systematically to the next sites.
A 66-year-old woman is retiring and will no longer have a health insurance through
her place of employment. Which agency should the client be referred to by the
employee health nurse for health insurance needs?
a- Woman, Infant, and Children program
b- Medicaid
c- Medicare
d- Consolidated Omnibus Budget Reconciliation Act provision. - ANSWER: Medicare
*Rationale: Title XVII of the social security Act of 1965 created Medicare Program to
provide medical insurance for person more than 65 years or older, disable or with
permeant kidney failure, WIC provides supplemental nutrition to meet the needs of
pregnant of breastfeeding woman, infants and children up to age of 6.
A client who is taking an oral dose of a tetracycline complains of gastrointestinal
upset. What snack should the nurse instruct the client to take with the tetracycline?
a- Fruit-flavored yogurt.
b- Cheese and crackers.
c- Cold cereal with skim milk.
d- Toasted wheat bread and jelly - ANSWER: Toasted wheat bread and jelly
, *Rationale: Dairy products decrease the effect of tetracycline, so the nurse instructs
the client to eat a snack such as toast, which contains no dairy products and may
decrease GI symptoms.
Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication?
a- "I am having pain in my lower back when I move my legs"
b- "My throat hurts when I swallow"
c- "I feel sick to my stomach and am going to throw up"
d- I have a headache that gets worse when I sit up" - ANSWER: "I have a headache
that gets worse when I sit up"
*Rationale: A post-lumbar puncture headache, ranging from mild to severe, may
occur as a result of leakage of cerebrospinal fluid at the puncture site. This
complication is usually managed by bedrest, analgesic, and hydration.
An elderly client seems confused and reports the onset of nausea, dysuria, and
urgency with incontinence. Which action should the nurse implement?
a- Auscultate for renal bruits
b- Obtain a clean catch mid-stream specimen
c- Use a dipstick to measure for urinary ketone
d- Begin to strain the client‟s urine. - ANSWER: Obtain a clean catch mid-stream
specimen
*Rationale: This elderly is experiencing symptoms of urinary tract infection. The
nurse should obtain a clean catch mid-stream specimen to determine the causative
agent so an anti-infective agent can be prescribed.
The nurse is assisting the mother of a child with
phenylketonuria (PKU) to select foods that are in keeping with the child‟s dietary
restrictions. Which foods are contraindicated for this child?
a- Wheat products
b- Foods sweetened with aspartame.
c- High fat foods
d- High calories foods. - ANSWER: Foods sweetened with aspartame
* Rationale: Aspartame should not be consumed by a child with PKU because ut is
converted to phenylalanine in the body. Additionally, milk and milk products are
contraindicated for children with PKU.
Before preparing a client for the first surgical case of the day, a part-time scrub nurse
asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation
for this client. Which response should the circulating nurse provide?
a- Ask a more experience nurse to perform that scrub since it is the first time of the
day
b- Validate the nurse is implementing the OR policy for surgical hand scrub
c- Inform the nurse that hand scrubs should be 3 minutes between cases.
d- Direct the nurse to continue the surgical hand scrub for a 5- minute duration. -
ANSWER: Direct the nurse to continue the surgical hand scrub for a 5- minute
duration
CORRECT DETAILED ANSWERS
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta)
for the past 12 days. Which assessment finding requires immediate follow-up?
a- Describes life without purpose
b- Complains of nausea and loss of appetite
c- States is often fatigued and drowsy
d- Exhibits an increase in sweating. - ANSWER: Describes life without purpose
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer.
Her Papanicolau (Pap) smear results are negative. What information should the
nurse include in the client‟s teaching plan?
a- Further evaluation involving surgery may be needed
b- A pelvic exam is also needed before cancer is ruled out
c- Pap smear evaluation should be continued every six month
d- One additional negative pap smear in six months is needed. - ANSWER: Further
evaluation involving surgery may be need
A client who recently underwear a tracheostomy is being prepared for discharge to
home. Which instructions is most important for the nurse to include in the discharge
plan?
a- Explain how to use communication tools.
b- Teach tracheal suctioning techniques
c- Encourage self-care and independence.
d- Demonstrate how to clean tracheostomy site. - ANSWER: Teach tracheal
suctioning techniques
. In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client‟s
respiratory rate is 14 breaths / minute. What action should the nurse implement?
a- Encourage the client to take deep breaths
b- Remove the mask to deflate the bag
c- Increase the liter flow of oxygen
d- Document the assessment data - ANSWER: Document the assessment data
Rational: Reservoir bag should not deflate completely during inspiration and the
clients respiratory rate is WNL
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What action should the nurse take first?
a- Give the client 4 ounces of orange juice
b- Call 911 to summon emergency assistance
c- Check the client for lacerations or fractures
,d- Asses clients blood sugar level - ANSWER: Check the client for lacerations or
fractures
* Rationale: After the client falls, the nurse should immediately assess for the
possibility of injuries and provide first aid as needed
. At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at 0400 because she
wanted to avoid getting a headache. Which action should the nurse take first?
a- Ensure preoperative lab results are available
b- Start prescribed IV with lactated Ringer‟s
c- Inform the anesthesia care provider
d- Contact the client‟s obstetrician. - ANSWER: Inform the anesthesia care provider
*Rationale: Surgical preoperative instruction includes NPO after midnight the day of
surgery to decrease the risk of aspiration should vomiting occur during anesthesia.
While it is possible the C-section will be done on schedule or rescheduled for later in
the day, the anesthesia provider should be notified first.
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first?
a- Side the stethoscope across the sternum.
b- Move the stethoscope to the mitral site
c- Listen with the bell at the same location
d- Observe the cardiac telemetry monitor - ANSWER: Listen with the bell at the same
location
*Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds
such as S3 and S4. The nurse listens at the same site using the diaphragm the
diaphragm and bell before moving systematically to the next sites.
A 66-year-old woman is retiring and will no longer have a health insurance through
her place of employment. Which agency should the client be referred to by the
employee health nurse for health insurance needs?
a- Woman, Infant, and Children program
b- Medicaid
c- Medicare
d- Consolidated Omnibus Budget Reconciliation Act provision. - ANSWER: Medicare
*Rationale: Title XVII of the social security Act of 1965 created Medicare Program to
provide medical insurance for person more than 65 years or older, disable or with
permeant kidney failure, WIC provides supplemental nutrition to meet the needs of
pregnant of breastfeeding woman, infants and children up to age of 6.
A client who is taking an oral dose of a tetracycline complains of gastrointestinal
upset. What snack should the nurse instruct the client to take with the tetracycline?
a- Fruit-flavored yogurt.
b- Cheese and crackers.
c- Cold cereal with skim milk.
d- Toasted wheat bread and jelly - ANSWER: Toasted wheat bread and jelly
, *Rationale: Dairy products decrease the effect of tetracycline, so the nurse instructs
the client to eat a snack such as toast, which contains no dairy products and may
decrease GI symptoms.
Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication?
a- "I am having pain in my lower back when I move my legs"
b- "My throat hurts when I swallow"
c- "I feel sick to my stomach and am going to throw up"
d- I have a headache that gets worse when I sit up" - ANSWER: "I have a headache
that gets worse when I sit up"
*Rationale: A post-lumbar puncture headache, ranging from mild to severe, may
occur as a result of leakage of cerebrospinal fluid at the puncture site. This
complication is usually managed by bedrest, analgesic, and hydration.
An elderly client seems confused and reports the onset of nausea, dysuria, and
urgency with incontinence. Which action should the nurse implement?
a- Auscultate for renal bruits
b- Obtain a clean catch mid-stream specimen
c- Use a dipstick to measure for urinary ketone
d- Begin to strain the client‟s urine. - ANSWER: Obtain a clean catch mid-stream
specimen
*Rationale: This elderly is experiencing symptoms of urinary tract infection. The
nurse should obtain a clean catch mid-stream specimen to determine the causative
agent so an anti-infective agent can be prescribed.
The nurse is assisting the mother of a child with
phenylketonuria (PKU) to select foods that are in keeping with the child‟s dietary
restrictions. Which foods are contraindicated for this child?
a- Wheat products
b- Foods sweetened with aspartame.
c- High fat foods
d- High calories foods. - ANSWER: Foods sweetened with aspartame
* Rationale: Aspartame should not be consumed by a child with PKU because ut is
converted to phenylalanine in the body. Additionally, milk and milk products are
contraindicated for children with PKU.
Before preparing a client for the first surgical case of the day, a part-time scrub nurse
asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation
for this client. Which response should the circulating nurse provide?
a- Ask a more experience nurse to perform that scrub since it is the first time of the
day
b- Validate the nurse is implementing the OR policy for surgical hand scrub
c- Inform the nurse that hand scrubs should be 3 minutes between cases.
d- Direct the nurse to continue the surgical hand scrub for a 5- minute duration. -
ANSWER: Direct the nurse to continue the surgical hand scrub for a 5- minute
duration
