HESI RN Exit Exam c c c
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he
c c c c c c c c c c c c c c
will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. W
c c c c c c c c c c c c c c c c
hat is the best follow-up action by the nurse?
c c c c c c c c
a. Remind the client that it is also important to switch to decaffeinated coffee and tea
c c c c c c c c c c c c c c
.
b. Suggest that the client also plan to eat frequent small meals to reduce discomfort
c c c c c c c c c c c c c
c. Review with the client the need to avoid foods that are rich in milk and cream.
c c c c c c c c c c c c c c c
d. Reinforce this teaching by asking the client to list a dairy food that he might sel
c c c c c c c c c c c c c c c
ect.
(ANS- Review with the client the need to avoid foods that are rich in milk and cream
c c c c c c c c c c c c c c c c
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be
c c c c c c c c c c c c c c
avoided.
A male client with hypertension, who received new antihypertensive prescriptions at
c c c c c c c c c c c
his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP).
c c c c c c c c c c c c c c c c
His BP is 158/106 and he admits that he has not been taking the prescribed medicatio
c c c c c c c c c c c c c c c
n because the drugs make him "feel bad". In explaining the need for hypertension con
c c c c c c c c c c c c c c
trol, the nurse should stress that an elevated BP places the client at risk for which path
c c c c c c c c c c c c c c c c
ophysiological condition? c
a. Blindness secondary to cataracts c c c
b. Acute kidney injury due to glomerular damage
c c c c c c
c. Stroke secondary to hemorrhage c c c
d. Heart block due to myocardial damage (
c c c c c c
ANS- Stroke secondary to hemorrhage
c c c c
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled hyperte
c c c c c c c c c c c
nsion.
,The nurse observes an unlicensed assistive personnel (UAP) positioning a newly adm
c c c c c c c c c c c
itted client who has a seizure disorder. The client is supine and the UAP is placing soft
c c c c c c c c c c c c c c c c
pillows along the side rails. What action should the nurse implement?
c c c c c c c c c c c
a. Ensure that the UAP has placed the pillows effectively to protect the client.
c c c c c c c c c c c c
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pil
c c c c c c c c c c c c c c c
lows.
c. Assume responsibility for placing the pillows while the UAP completes another ta
c c c c c c c c c c c
sk.
d. Ask the UAP to use some of the pillows to prop the client in a side lying pos
c c c c c c c c c c c c c c c c c
ition.
(ANS-
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
c c c c c c c c c c c c c c c c
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest b
c c c c c c c c c c c c c c c
ecause the use of pillows could result in suffocation and would need to be removed at
c c c c c c c c c c c c c c c c
the onset of the seizure. The nurse can delegate paddling the side rails to the UAP
c c c c c c c c c c c c c c c
An adolescent with major depressive disorder has been taking duloxetine (Cymb
c c c c c c c c c c
alta) for the past 12 days. Which assessment finding requires immediate follow-
c c c c c c c c c c c
up
a. Describes life without purpose c c c
b. Complains of nausea and loss of appetite c c c c c c
c. States is often fatigued and drowsy
c c c c c
d. Exhibits an increase in sweating. (A c c c c c
NS- Describes life without purpose
c c c c
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that
c c c c c c c c c c
is known to increase the risk of suicidal thinking in adolescents and young adults with
c c c c c c c c c c c c c c c c
major depressive disorder. B, C and D are side effects
c c c c c c c c c
,A 60-year-
c
old female client with a positive family history of ovarian cancer has developed an ab
c c c c c c c c c c c c c c
dominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (P
c c c c c c c c c c c c
ap) smear results are negative. What information should the nurse include in the clien
c c c c c c c c c c c c c
t's teaching plan
c c
a. Further evaluation involving surgery may be needed
c c c c c c
b. A pelvic exam is also needed before cancer is ruled out
c c c c c c c c c c
c. Pap smear evaluation should be continued every six month
c c c c c c c c
d. One additional negative pap smear in six months is needed. (
c c c c c c c c c c
ANS- Further evaluation involving surgery may be needed
c c c c c c c
Rationale: An abdominal mass in a client with a family history for ovarian cancer sho
c c c c c c c c c c c c c c
uld be evaluated carefully
c c c
A client who recently underwent a tracheostomy is being prepared for discharge to ho
c c c c c c c c c c c c c
me. Which instructions is most important for the nurse to include in the discharge pla
c c c c c c c c c c c c c c
n?
a. Explain how to use communication tools. c c c c c
b. Teach tracheal suctioning techniques c c c
c. Encourage self-care and independence. c c c
d. Demonstrate how to clean tracheostomy site. ( c c c c c c
ANS- Teach tracheal suctioning techniques
c c c c
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is
c c c c c c c c c c c c c
critical.
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxyg
c c c c c c c c c c c c c c c
en reservoir bag does not deflate completely during inspiration and the client's respirato
c c c c c c c c c c c c
ry rate is 14 breaths / minute. What action should the nurse implement
c c c c c c c c c c c c
a. Encourage the client to take deep breaths c c c c c c
b. Remove the mask to deflate the bag c c c c c c
c. Increase the liter flow of oxygen c c c c c
d. Document the assessment data c c c
, (ANS- Document the assessment data
c c c c
Rationale: reservoir bag should not deflate completely during inspiration and the clie
c c c c c c c c c c c
nt's respiratory rate is within normal limits.
c c c c c c
During shift report, the central electrocardiogram (EKG) monitoring system alarms.
c c c c c c c c c c
Which client alarm should the nurse investigate first?
c c c c c c c
a. Respiratory apnea of 30 seconds c c c c
b. Oxygen saturation rate of 88% c c c c
c. Eight premature ventricular beats every minute
c c c c c
d. Disconnected monitor signal for the last 6 minutes. ( c c c c c c c c
ANS- Respiratory apnea of 30 seconds
c c c c c
Rationale: The priority is the client whose alarm indicating respiratory apnea that shoul
c c c c c c c c c c c c
d be assessed first.
c c c
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
c c c c c c c c c c c c c c c
What action should the nurse take first?
c c c c c c
a. Give the client 4 ounces of orange juice
c c c c c c c
b. Call 911 to summon emergency assistance
c c c c c
c. Check the client for lacerations or fracturesc c c c c c
d. Asses clients blood sugar level (ANS- c c c c c
Check the client for lacerations or fractures
c c c c c c c
Rationale: After the client falls, the nurse should immediately assess for the possibility
c c c c c c c c c c c c c
of injuries and provide first aid as needed
c c c c c c c
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
c c c c c c c c c c c c
cSection), the client tells the nurse that she drank a cup a coffee at 0400 because she wan
c c c c c c c c c c c c c c c c c
ted to avoid getting a headache. Which action should the nurse take first?
c c c c c c c c c c c c
a. Ensure preoperative lab results are available c c c c c
b. Start prescribed IV with lactated Ringer's
c c c c c
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he
c c c c c c c c c c c c c c
will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. W
c c c c c c c c c c c c c c c c
hat is the best follow-up action by the nurse?
c c c c c c c c
a. Remind the client that it is also important to switch to decaffeinated coffee and tea
c c c c c c c c c c c c c c
.
b. Suggest that the client also plan to eat frequent small meals to reduce discomfort
c c c c c c c c c c c c c
c. Review with the client the need to avoid foods that are rich in milk and cream.
c c c c c c c c c c c c c c c
d. Reinforce this teaching by asking the client to list a dairy food that he might sel
c c c c c c c c c c c c c c c
ect.
(ANS- Review with the client the need to avoid foods that are rich in milk and cream
c c c c c c c c c c c c c c c c
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be
c c c c c c c c c c c c c c
avoided.
A male client with hypertension, who received new antihypertensive prescriptions at
c c c c c c c c c c c
his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP).
c c c c c c c c c c c c c c c c
His BP is 158/106 and he admits that he has not been taking the prescribed medicatio
c c c c c c c c c c c c c c c
n because the drugs make him "feel bad". In explaining the need for hypertension con
c c c c c c c c c c c c c c
trol, the nurse should stress that an elevated BP places the client at risk for which path
c c c c c c c c c c c c c c c c
ophysiological condition? c
a. Blindness secondary to cataracts c c c
b. Acute kidney injury due to glomerular damage
c c c c c c
c. Stroke secondary to hemorrhage c c c
d. Heart block due to myocardial damage (
c c c c c c
ANS- Stroke secondary to hemorrhage
c c c c
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled hyperte
c c c c c c c c c c c
nsion.
,The nurse observes an unlicensed assistive personnel (UAP) positioning a newly adm
c c c c c c c c c c c
itted client who has a seizure disorder. The client is supine and the UAP is placing soft
c c c c c c c c c c c c c c c c
pillows along the side rails. What action should the nurse implement?
c c c c c c c c c c c
a. Ensure that the UAP has placed the pillows effectively to protect the client.
c c c c c c c c c c c c
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pil
c c c c c c c c c c c c c c c
lows.
c. Assume responsibility for placing the pillows while the UAP completes another ta
c c c c c c c c c c c
sk.
d. Ask the UAP to use some of the pillows to prop the client in a side lying pos
c c c c c c c c c c c c c c c c c
ition.
(ANS-
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
c c c c c c c c c c c c c c c c
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest b
c c c c c c c c c c c c c c c
ecause the use of pillows could result in suffocation and would need to be removed at
c c c c c c c c c c c c c c c c
the onset of the seizure. The nurse can delegate paddling the side rails to the UAP
c c c c c c c c c c c c c c c
An adolescent with major depressive disorder has been taking duloxetine (Cymb
c c c c c c c c c c
alta) for the past 12 days. Which assessment finding requires immediate follow-
c c c c c c c c c c c
up
a. Describes life without purpose c c c
b. Complains of nausea and loss of appetite c c c c c c
c. States is often fatigued and drowsy
c c c c c
d. Exhibits an increase in sweating. (A c c c c c
NS- Describes life without purpose
c c c c
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that
c c c c c c c c c c
is known to increase the risk of suicidal thinking in adolescents and young adults with
c c c c c c c c c c c c c c c c
major depressive disorder. B, C and D are side effects
c c c c c c c c c
,A 60-year-
c
old female client with a positive family history of ovarian cancer has developed an ab
c c c c c c c c c c c c c c
dominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (P
c c c c c c c c c c c c
ap) smear results are negative. What information should the nurse include in the clien
c c c c c c c c c c c c c
t's teaching plan
c c
a. Further evaluation involving surgery may be needed
c c c c c c
b. A pelvic exam is also needed before cancer is ruled out
c c c c c c c c c c
c. Pap smear evaluation should be continued every six month
c c c c c c c c
d. One additional negative pap smear in six months is needed. (
c c c c c c c c c c
ANS- Further evaluation involving surgery may be needed
c c c c c c c
Rationale: An abdominal mass in a client with a family history for ovarian cancer sho
c c c c c c c c c c c c c c
uld be evaluated carefully
c c c
A client who recently underwent a tracheostomy is being prepared for discharge to ho
c c c c c c c c c c c c c
me. Which instructions is most important for the nurse to include in the discharge pla
c c c c c c c c c c c c c c
n?
a. Explain how to use communication tools. c c c c c
b. Teach tracheal suctioning techniques c c c
c. Encourage self-care and independence. c c c
d. Demonstrate how to clean tracheostomy site. ( c c c c c c
ANS- Teach tracheal suctioning techniques
c c c c
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is
c c c c c c c c c c c c c
critical.
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxyg
c c c c c c c c c c c c c c c
en reservoir bag does not deflate completely during inspiration and the client's respirato
c c c c c c c c c c c c
ry rate is 14 breaths / minute. What action should the nurse implement
c c c c c c c c c c c c
a. Encourage the client to take deep breaths c c c c c c
b. Remove the mask to deflate the bag c c c c c c
c. Increase the liter flow of oxygen c c c c c
d. Document the assessment data c c c
, (ANS- Document the assessment data
c c c c
Rationale: reservoir bag should not deflate completely during inspiration and the clie
c c c c c c c c c c c
nt's respiratory rate is within normal limits.
c c c c c c
During shift report, the central electrocardiogram (EKG) monitoring system alarms.
c c c c c c c c c c
Which client alarm should the nurse investigate first?
c c c c c c c
a. Respiratory apnea of 30 seconds c c c c
b. Oxygen saturation rate of 88% c c c c
c. Eight premature ventricular beats every minute
c c c c c
d. Disconnected monitor signal for the last 6 minutes. ( c c c c c c c c
ANS- Respiratory apnea of 30 seconds
c c c c c
Rationale: The priority is the client whose alarm indicating respiratory apnea that shoul
c c c c c c c c c c c c
d be assessed first.
c c c
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
c c c c c c c c c c c c c c c
What action should the nurse take first?
c c c c c c
a. Give the client 4 ounces of orange juice
c c c c c c c
b. Call 911 to summon emergency assistance
c c c c c
c. Check the client for lacerations or fracturesc c c c c c
d. Asses clients blood sugar level (ANS- c c c c c
Check the client for lacerations or fractures
c c c c c c c
Rationale: After the client falls, the nurse should immediately assess for the possibility
c c c c c c c c c c c c c
of injuries and provide first aid as needed
c c c c c c c
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
c c c c c c c c c c c c
cSection), the client tells the nurse that she drank a cup a coffee at 0400 because she wan
c c c c c c c c c c c c c c c c c
ted to avoid getting a headache. Which action should the nurse take first?
c c c c c c c c c c c c
a. Ensure preoperative lab results are available c c c c c
b. Start prescribed IV with lactated Ringer's
c c c c c
