HESI RN Exit Exam m m m
Following discharge teaching, a male client with duodenal ulcer tells the nurse the
m m m m m m m m m m m m m
he will drink plenty of dairy products, such as milk, to help coat and protect his ul
m m m m m m m m m m m m m m m m
cer. What is the best follow-up action by the nurse?
m m m m m m m m m
a. Remind the client that it is also important to switch to decaffeinated coffee an
m m m m m m m m m m m m m
d tea.
m
b. Suggest that the client also plan to eat frequent small meals to reduce discomfort
m m m m m m m m m m m m m
c. Review with the client the need to avoid foods that are rich in milk and cream.
m m m m m m m m m m m m m m m
d. Reinforce this teaching by asking the client to list a dairy food that he migh
m m m m m m m m m m m m m m
t select.
m
(ANS-
mReview with the client the need to avoid foods that are rich in milk and cream
m m m m m m m m m m m m m m m
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should
m m m m m m m m m m m m
be avoided.
m m
A male client with hypertension, who received new antihypertensive prescriptions
m m m m m m m m m
mat his last visit returns to the clinic two weeks later to evaluate his blood pressur
m m m m m m m m m m m m m m m
e (BP). His BP is 158/106 and he admits that he has not been taking the prescribe
m m m m m m m m m m m m m m m m
d medication because the drugs make him "feel bad". In explaining the need for h
m m m m m m m m m m m m m m
ypertension control, the nurse should stress that an elevated BP places the client a
m m m m m m m m m m m m m
t risk for which pathophysiological condition?
m m m m m
a. Blindness secondary to cataracts m m m
b. Acute kidney injury due to glomerular damage
m m m m m m
c. Stroke secondary to hemorrhage m m m
d. Heart block due to myocardial damage
m m m m m
m(ANS- Stroke secondary to hemorrhage
m m m m
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled hyp
m m m m m m m m m m m
ertension.
,The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
m m m m m m m m m m m
admitted client who has a seizure disorder. The client is supine and the UAP is pl
m m m m m m m m m m m m m m m
acing soft pillows along the side rails. What action should the nurse implement?
m m m m m m m m m m m m
a. Ensure that the UAP has placed the pillows effectively to protect the client.
m m m m m m m m m m m m
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead o
m m m m m m m m m m m m m m
f pillows.
m
c. Assume responsibility for placing the pillows while the UAP completes anothe
m m m m m m m m m m
r task.
m
d. Ask the UAP to use some of the pillows to prop the client in a side lyin
m m m m m m m m m m m m m m m m
g position.
m
(ANS-
mInstruct the UAP to obtain soft blankets to secure to the side rails instead of pillo
m m m m m m m m m m m m m m m
ws
Rationale: The nurse should instruct the UAP to pad the side rails with soft blank
m m m m m m m m m m m m m m
est because the use of pillows could result in suffocation and would need to be re
m m m m m m m m m m m m m m m
moved at the onset of the seizure. The nurse can delegate paddling the side rails t
m m m m m m m m m m m m m m m
o the UAP
m m
An adolescent with major depressive disorder has been taking duloxetine (Cy
m m m m m m m m m m
mbalta) for the past 12 days. Which assessment finding requires immediate fol
m m m m m m m m m m m
low-up
a. Describes life without purpose m m m
b. Complains of nausea and loss of appetite m m m m m m
c. States is often fatigued and drowsy
m m m m m
d. Exhibits an increase in sweating. ( m m m m m
ANS- Describes life without purpose
m m m m
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor
m m m m m m m m m m
that is known to increase the risk of suicidal thinking in adolescents and young ad
m m m m m m m m m m m m m m
ults with major depressive disorder. B, C and D are side effects
m m m m m m m m m m m
,A 60-year-
m
old female client with a positive family history of ovarian cancer has developed an
m m m m m m m m m m m m m
mabdominal mass and is being evaluated for possible ovarian cancer. Her Papanicol
m m m m m m m m m m m
au (Pap) smear results are negative. What information should the nurse include in
m m m m m m m m m m m m m
the client's teaching plan
m m m
a. Further evaluation involving surgery may be needed
m m m m m m
b. A pelvic exam is also needed before cancer is ruled out
m m m m m m m m m m
c. Pap smear evaluation should be continued every six month
m m m m m m m m
d. One additional negative pap smear in six months is needed
m m m m m m m m m
. (ANS- Further evaluation involving surgery may be needed
m m m m m m m m
Rationale: An abdominal mass in a client with a family history for ovarian cancer
m m m m m m m m m m m m m m
should be evaluated carefully
m m m
A client who recently underwent a tracheostomy is being prepared for discharge t
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o home. Which instructions is most important for the nurse to include in the disch
m m m m m m m m m m m m m m
arge plan? m
a. Explain how to use communication tools.
m m m m m
b. Teach tracheal suctioning techniques
m m m
c. Encourage self-care and independence. m m m
d. Demonstrate how to clean tracheostomy site. m m m m m
m(ANS- Teach tracheal suctioning techniques
m m m m
Rationale: Suctioning helps to clear secretions and maintain an open airway, which
m m m m m m m m m m m
is critical.
m m
In assessing an adult client with a partial rebreather mask, the nurse notes that the
m m m m m m m m m m m m m m m
oxygen reservoir bag does not deflate completely during inspiration and the client'
m m m m m m m m m m m
s respiratory rate is 14 breaths / minute. What action should the nurse implement
m m m m m m m m m m m m m
a. Encourage the client to take deep breathsm m m m m m
b. Remove the mask to deflate the bag
m m m m m m
c. Increase the liter flow of oxygenm m m m m
d. Document the assessment data m m m
, (ANS- Document the assessment data
m m m m
Rationale: reservoir bag should not deflate completely during inspiration and the c
m m m m m m m m m m m
lient's respiratory rate is within normal limits.
m m m m m m
During shift report, the central electrocardiogram (EKG) monitoring system alarm
m m m m m m m m m
s. Which client alarm should the nurse investigate first?
m m m m m m m m
a. Respiratory apnea of 30 seconds m m m m
b. Oxygen saturation rate of 88% m m m m
c. Eight premature ventricular beats every minute
m m m m m
d. Disconnected monitor signal for the last 6 minutes m m m m m m m
. (ANS- Respiratory apnea of 30 seconds
m m m m m m
Rationale: The priority is the client whose alarm indicating respiratory apnea that s
m m m m m m m m m m m m
hould be assessed first.
m m m
During a home visit, the nurse observed an elderly client with diabetes slip and f
m m m m m m m m m m m m m m
all. What action should the nurse take first?
m m m m m m m
a. Give the client 4 ounces of orange juice
m m m m m m m
b. Call 911 to summon emergency assistance
m m m m m
c. Check the client for lacerations or fractures
m m m m m m
d. Asses clients blood sugar level (ANS-
m m m m m
mCheck the client for lacerations or fractures
m m m m m m
Rationale: After the client falls, the nurse should immediately assess for the possib
m m m m m m m m m m m m
ility of injuries and provide first aid as needed
m m m m m m m m
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
m m m m m m m m m m m m
mSection), the client tells the nurse that she drank a cup a coffee at 0400 because sh
m m m m m m m m m m m m m m m m
e wanted to avoid getting a headache. Which action should the nurse take first?
m m m m m m m m m m m m m
a. Ensure preoperative lab results are available
m m m m m
b. Start prescribed IV with lactated Ringer's
m m m m m
Following discharge teaching, a male client with duodenal ulcer tells the nurse the
m m m m m m m m m m m m m
he will drink plenty of dairy products, such as milk, to help coat and protect his ul
m m m m m m m m m m m m m m m m
cer. What is the best follow-up action by the nurse?
m m m m m m m m m
a. Remind the client that it is also important to switch to decaffeinated coffee an
m m m m m m m m m m m m m
d tea.
m
b. Suggest that the client also plan to eat frequent small meals to reduce discomfort
m m m m m m m m m m m m m
c. Review with the client the need to avoid foods that are rich in milk and cream.
m m m m m m m m m m m m m m m
d. Reinforce this teaching by asking the client to list a dairy food that he migh
m m m m m m m m m m m m m m
t select.
m
(ANS-
mReview with the client the need to avoid foods that are rich in milk and cream
m m m m m m m m m m m m m m m
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should
m m m m m m m m m m m m
be avoided.
m m
A male client with hypertension, who received new antihypertensive prescriptions
m m m m m m m m m
mat his last visit returns to the clinic two weeks later to evaluate his blood pressur
m m m m m m m m m m m m m m m
e (BP). His BP is 158/106 and he admits that he has not been taking the prescribe
m m m m m m m m m m m m m m m m
d medication because the drugs make him "feel bad". In explaining the need for h
m m m m m m m m m m m m m m
ypertension control, the nurse should stress that an elevated BP places the client a
m m m m m m m m m m m m m
t risk for which pathophysiological condition?
m m m m m
a. Blindness secondary to cataracts m m m
b. Acute kidney injury due to glomerular damage
m m m m m m
c. Stroke secondary to hemorrhage m m m
d. Heart block due to myocardial damage
m m m m m
m(ANS- Stroke secondary to hemorrhage
m m m m
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled hyp
m m m m m m m m m m m
ertension.
,The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
m m m m m m m m m m m
admitted client who has a seizure disorder. The client is supine and the UAP is pl
m m m m m m m m m m m m m m m
acing soft pillows along the side rails. What action should the nurse implement?
m m m m m m m m m m m m
a. Ensure that the UAP has placed the pillows effectively to protect the client.
m m m m m m m m m m m m
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead o
m m m m m m m m m m m m m m
f pillows.
m
c. Assume responsibility for placing the pillows while the UAP completes anothe
m m m m m m m m m m
r task.
m
d. Ask the UAP to use some of the pillows to prop the client in a side lyin
m m m m m m m m m m m m m m m m
g position.
m
(ANS-
mInstruct the UAP to obtain soft blankets to secure to the side rails instead of pillo
m m m m m m m m m m m m m m m
ws
Rationale: The nurse should instruct the UAP to pad the side rails with soft blank
m m m m m m m m m m m m m m
est because the use of pillows could result in suffocation and would need to be re
m m m m m m m m m m m m m m m
moved at the onset of the seizure. The nurse can delegate paddling the side rails t
m m m m m m m m m m m m m m m
o the UAP
m m
An adolescent with major depressive disorder has been taking duloxetine (Cy
m m m m m m m m m m
mbalta) for the past 12 days. Which assessment finding requires immediate fol
m m m m m m m m m m m
low-up
a. Describes life without purpose m m m
b. Complains of nausea and loss of appetite m m m m m m
c. States is often fatigued and drowsy
m m m m m
d. Exhibits an increase in sweating. ( m m m m m
ANS- Describes life without purpose
m m m m
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor
m m m m m m m m m m
that is known to increase the risk of suicidal thinking in adolescents and young ad
m m m m m m m m m m m m m m
ults with major depressive disorder. B, C and D are side effects
m m m m m m m m m m m
,A 60-year-
m
old female client with a positive family history of ovarian cancer has developed an
m m m m m m m m m m m m m
mabdominal mass and is being evaluated for possible ovarian cancer. Her Papanicol
m m m m m m m m m m m
au (Pap) smear results are negative. What information should the nurse include in
m m m m m m m m m m m m m
the client's teaching plan
m m m
a. Further evaluation involving surgery may be needed
m m m m m m
b. A pelvic exam is also needed before cancer is ruled out
m m m m m m m m m m
c. Pap smear evaluation should be continued every six month
m m m m m m m m
d. One additional negative pap smear in six months is needed
m m m m m m m m m
. (ANS- Further evaluation involving surgery may be needed
m m m m m m m m
Rationale: An abdominal mass in a client with a family history for ovarian cancer
m m m m m m m m m m m m m m
should be evaluated carefully
m m m
A client who recently underwent a tracheostomy is being prepared for discharge t
m m m m m m m m m m m m
o home. Which instructions is most important for the nurse to include in the disch
m m m m m m m m m m m m m m
arge plan? m
a. Explain how to use communication tools.
m m m m m
b. Teach tracheal suctioning techniques
m m m
c. Encourage self-care and independence. m m m
d. Demonstrate how to clean tracheostomy site. m m m m m
m(ANS- Teach tracheal suctioning techniques
m m m m
Rationale: Suctioning helps to clear secretions and maintain an open airway, which
m m m m m m m m m m m
is critical.
m m
In assessing an adult client with a partial rebreather mask, the nurse notes that the
m m m m m m m m m m m m m m m
oxygen reservoir bag does not deflate completely during inspiration and the client'
m m m m m m m m m m m
s respiratory rate is 14 breaths / minute. What action should the nurse implement
m m m m m m m m m m m m m
a. Encourage the client to take deep breathsm m m m m m
b. Remove the mask to deflate the bag
m m m m m m
c. Increase the liter flow of oxygenm m m m m
d. Document the assessment data m m m
, (ANS- Document the assessment data
m m m m
Rationale: reservoir bag should not deflate completely during inspiration and the c
m m m m m m m m m m m
lient's respiratory rate is within normal limits.
m m m m m m
During shift report, the central electrocardiogram (EKG) monitoring system alarm
m m m m m m m m m
s. Which client alarm should the nurse investigate first?
m m m m m m m m
a. Respiratory apnea of 30 seconds m m m m
b. Oxygen saturation rate of 88% m m m m
c. Eight premature ventricular beats every minute
m m m m m
d. Disconnected monitor signal for the last 6 minutes m m m m m m m
. (ANS- Respiratory apnea of 30 seconds
m m m m m m
Rationale: The priority is the client whose alarm indicating respiratory apnea that s
m m m m m m m m m m m m
hould be assessed first.
m m m
During a home visit, the nurse observed an elderly client with diabetes slip and f
m m m m m m m m m m m m m m
all. What action should the nurse take first?
m m m m m m m
a. Give the client 4 ounces of orange juice
m m m m m m m
b. Call 911 to summon emergency assistance
m m m m m
c. Check the client for lacerations or fractures
m m m m m m
d. Asses clients blood sugar level (ANS-
m m m m m
mCheck the client for lacerations or fractures
m m m m m m
Rationale: After the client falls, the nurse should immediately assess for the possib
m m m m m m m m m m m m
ility of injuries and provide first aid as needed
m m m m m m m m
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
m m m m m m m m m m m m
mSection), the client tells the nurse that she drank a cup a coffee at 0400 because sh
m m m m m m m m m m m m m m m m
e wanted to avoid getting a headache. Which action should the nurse take first?
m m m m m m m m m m m m m
a. Ensure preoperative lab results are available
m m m m m
b. Start prescribed IV with lactated Ringer's
m m m m m
