EXIT HESI - Comprehensive PN Exam A
Practice Questions
A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my
breasts after the baby sucks for a few minutes?" Which information should the nurse
provide?
A.This feeling occurs during feeding with a breast infection.
B.This sensation occurs as breast milk moves to the nipple.
C.The baby does not have a good latch-on.
D.The infant is not positioned correctly. - ANS-B
When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they
feel a tingling sensation in their nipples (B) when let-down occurs. (A, C, and D) provide
inaccurate information.
\A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational
health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which
intervention should the nurse implement first? - ANS-Check the client's blood pressure.
\A 50-year-old man arrives at the clinic with complaints of pain from ejaculation. Which
action should the nurse implement? - ANS-Ask about scrotal pain or blood in the semen.
\A 77-year-old female client states that she has never been so large around the waist and
that she has frequent periods of constipation. Colon disease has been ruled out with a
flexible sigmoidoscopy. Which information should the nurse provide to this client? -
ANS-With age, more fatty tissue develops in the abdomen and decreased intestinal
movement can cause constipation.
\A child is having a generalized tonic-clonic seizure. Which action should the nurse take?
A.Move objects out of the child's immediate area.
B.Quickly slip soft restraints on the child's wrists.
C.Insert a padded tongue blade between the teeth.
D.Place in the recovery position before going for help. - ANS-A
The first priority during a seizure is to provide a safe environment, so the nurse should clear
the area (A) to reduce the risk of trauma. The child should not be restrained (B) because this
may cause more trauma. Objects should not be placed in the child's mouth (C) because it
may pose a choking hazard. Although (D) should be implemented after the seizure, the
nurse should not leave the child during a seizure to get help.
\A child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of
breakfast foods at a fast food restaurant indicates that the mother understands the dietary
guidelines necessary for her child? - ANS-Toasted oat cereal and low-fat milk
\A client has been on a mechanical ventilator for several days. What should the nurse use to
document and record this client's respirations? - ANS-The ventilator setting for respiratory
rate and the client-initiated respirations
\A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days.
The UAP reports to the nurse that the client has had three loose foul-smelling stools this
,morning. Which intervention is most important for the nurse to implement? - ANS-Obtain a
stool specimen for culture and sensitivity.
\A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this
client likely to be exhibiting?
A.Hyperexcitability of reflexes
B.Hyperextension of the head and back
C.Inability to flex the chin to the chest
D.Lateral facial paralysis - ANS-C
Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by
attempting to flex the neck and place the chin to the chest (C). Although (A, B, and D) may
occur in meningitis, (A) describes exaggerated spinal nerve reflex responses, (B) describes
opisthotonus, and (D) may be related to cranial nerve pathology of the trigeminal nerve.
\A client is admitted to the mental health unit with a chief complaint of crying, depressed
mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I
can't believe this happened." Which statement by the nurse is most therapeutic? - ANS-"Tell
me more about how you're feeling."
\A client reports experiencing dysuria and urinary frequency. Which client teaching should
the nurse provide? - ANS-Save the next urine sample.
\A client tells the nurse that he is suffering from insomnia. Which information is most
important for the nurse to obtain? - ANS-The client's usual sleeping pattern
\A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client? - ANS-Sitting upright and forward with both arms
supported on an over the bed table
\A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy
with placement of ventilating tubes. Which response by the client indicates that further
teaching is necessary?
A."I will avoid coughing, sneezing, and forceful nose blowing."
B."Swimming can begin on the tenth postoperative day."
C."Any mild discomfort can be managed with acetaminophen."
D."Drainage from my ears is expected after the surgery." - ANS-B
The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and
drain fluid collection from the middle ear. The tube's patency allows air and water to enter the
middle ear, so the client should be reeducated if the client swims (B) or allows water to enter
the external ear. (A, C, and D) reflect correct responses.
\A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent
discharge. Which nursing intervention is most important in reducing the client's stress
associated with repeated hospitalization? - ANS-Encourage as much independence in
decision making as possible.
\A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is
initiated. Which complication is important for the nurse to monitor the client for at this time? -
ANS-Hypotension
\A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ)
PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's
serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium
level? - ANS-The client's renal function has affected his potassium level.
, \A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the
need for dialysis. Which information should the nurse provide the client prior to the test?
A.Failure to collect all urine specimens during the period of the study will invalidate the test.
B.Blood is collected to measure the amount of creatinine and determine the glomerular
filtration rate (GFR).
C.Dialysis is started when the GFR is lower than 5 mL/min.
D.Discard the first voiding, and record the time and amount of urine of each voiding for 24
hours. - ANS-A
Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear
serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all
urine should be collected during the period of the study or the results are inaccurate (A). As
renal function decreases, the creatinine level will decrease in the urine (B). Dialysis is
usually started when the GFR is 12 mL/min (C). There is no need to record the frequency
and amount of each voiding (D) during the time span of urine collection.
\A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The
nurse assists the client to a sitting position on the side of the bed. Which action should the
nurse implement next? - ANS-Allow the client to sit on the side of the bed for a few minutes
before transferring.
\A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse
determines that the client's hips are externally rotated. Which intervention is most important
for the nurse to implement?
A.Request a prescription for a bed board to provide increased back support.
B.Reposition the client so that both feet are supported by the bed board.
C.Move the trapeze bar to allow the client to pull with the upper extremities.
D.Place trochanter rolls on the lateral aspects of the client's thighs. - ANS-D
Trochanter rolls (D) should be placed on the lateral aspects of the thighs to prevent external
rotation of the hips when the client is in a supine position. Although (A, B, and C) are
supportive equipment used to maintain proper positioning of the client who is immobile, it is
most important to maintain the lower extremities in the aligned anatomical position. A bed
board (A) provides increased back support, especially with a soft mattress. The footboard
(B) maintains the feet in dorsiflexion and prevents foot drop. The trapeze bar (C) allows the
client to participate while turning in the bed, during transfers in and out of bed, or performing
upper arm exercises.
\A client with hepatic failure tells the nurse about recent use of acetaminophen (Tylenol).
How should the nurse respond to this client's statement? - ANS-The drug is hepatotoxic and
contraindicated.
\A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish
and swallow. Which information is most important for the nurse to provide the client? -
ANS-Oral hygiene should be performed before the medication.
\A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and
lying on the floor for 24 hours before being found. Which current client finding is indicative of
renal complications? - ANS-Blood urea nitrogen >25 mg/dL
\A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence
in the Middle East is soon going to destroy the entire world!" How should the nurse respond?
Practice Questions
A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my
breasts after the baby sucks for a few minutes?" Which information should the nurse
provide?
A.This feeling occurs during feeding with a breast infection.
B.This sensation occurs as breast milk moves to the nipple.
C.The baby does not have a good latch-on.
D.The infant is not positioned correctly. - ANS-B
When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they
feel a tingling sensation in their nipples (B) when let-down occurs. (A, C, and D) provide
inaccurate information.
\A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational
health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which
intervention should the nurse implement first? - ANS-Check the client's blood pressure.
\A 50-year-old man arrives at the clinic with complaints of pain from ejaculation. Which
action should the nurse implement? - ANS-Ask about scrotal pain or blood in the semen.
\A 77-year-old female client states that she has never been so large around the waist and
that she has frequent periods of constipation. Colon disease has been ruled out with a
flexible sigmoidoscopy. Which information should the nurse provide to this client? -
ANS-With age, more fatty tissue develops in the abdomen and decreased intestinal
movement can cause constipation.
\A child is having a generalized tonic-clonic seizure. Which action should the nurse take?
A.Move objects out of the child's immediate area.
B.Quickly slip soft restraints on the child's wrists.
C.Insert a padded tongue blade between the teeth.
D.Place in the recovery position before going for help. - ANS-A
The first priority during a seizure is to provide a safe environment, so the nurse should clear
the area (A) to reduce the risk of trauma. The child should not be restrained (B) because this
may cause more trauma. Objects should not be placed in the child's mouth (C) because it
may pose a choking hazard. Although (D) should be implemented after the seizure, the
nurse should not leave the child during a seizure to get help.
\A child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of
breakfast foods at a fast food restaurant indicates that the mother understands the dietary
guidelines necessary for her child? - ANS-Toasted oat cereal and low-fat milk
\A client has been on a mechanical ventilator for several days. What should the nurse use to
document and record this client's respirations? - ANS-The ventilator setting for respiratory
rate and the client-initiated respirations
\A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days.
The UAP reports to the nurse that the client has had three loose foul-smelling stools this
,morning. Which intervention is most important for the nurse to implement? - ANS-Obtain a
stool specimen for culture and sensitivity.
\A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this
client likely to be exhibiting?
A.Hyperexcitability of reflexes
B.Hyperextension of the head and back
C.Inability to flex the chin to the chest
D.Lateral facial paralysis - ANS-C
Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by
attempting to flex the neck and place the chin to the chest (C). Although (A, B, and D) may
occur in meningitis, (A) describes exaggerated spinal nerve reflex responses, (B) describes
opisthotonus, and (D) may be related to cranial nerve pathology of the trigeminal nerve.
\A client is admitted to the mental health unit with a chief complaint of crying, depressed
mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I
can't believe this happened." Which statement by the nurse is most therapeutic? - ANS-"Tell
me more about how you're feeling."
\A client reports experiencing dysuria and urinary frequency. Which client teaching should
the nurse provide? - ANS-Save the next urine sample.
\A client tells the nurse that he is suffering from insomnia. Which information is most
important for the nurse to obtain? - ANS-The client's usual sleeping pattern
\A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client? - ANS-Sitting upright and forward with both arms
supported on an over the bed table
\A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy
with placement of ventilating tubes. Which response by the client indicates that further
teaching is necessary?
A."I will avoid coughing, sneezing, and forceful nose blowing."
B."Swimming can begin on the tenth postoperative day."
C."Any mild discomfort can be managed with acetaminophen."
D."Drainage from my ears is expected after the surgery." - ANS-B
The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and
drain fluid collection from the middle ear. The tube's patency allows air and water to enter the
middle ear, so the client should be reeducated if the client swims (B) or allows water to enter
the external ear. (A, C, and D) reflect correct responses.
\A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent
discharge. Which nursing intervention is most important in reducing the client's stress
associated with repeated hospitalization? - ANS-Encourage as much independence in
decision making as possible.
\A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is
initiated. Which complication is important for the nurse to monitor the client for at this time? -
ANS-Hypotension
\A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ)
PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's
serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium
level? - ANS-The client's renal function has affected his potassium level.
, \A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the
need for dialysis. Which information should the nurse provide the client prior to the test?
A.Failure to collect all urine specimens during the period of the study will invalidate the test.
B.Blood is collected to measure the amount of creatinine and determine the glomerular
filtration rate (GFR).
C.Dialysis is started when the GFR is lower than 5 mL/min.
D.Discard the first voiding, and record the time and amount of urine of each voiding for 24
hours. - ANS-A
Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear
serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all
urine should be collected during the period of the study or the results are inaccurate (A). As
renal function decreases, the creatinine level will decrease in the urine (B). Dialysis is
usually started when the GFR is 12 mL/min (C). There is no need to record the frequency
and amount of each voiding (D) during the time span of urine collection.
\A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The
nurse assists the client to a sitting position on the side of the bed. Which action should the
nurse implement next? - ANS-Allow the client to sit on the side of the bed for a few minutes
before transferring.
\A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse
determines that the client's hips are externally rotated. Which intervention is most important
for the nurse to implement?
A.Request a prescription for a bed board to provide increased back support.
B.Reposition the client so that both feet are supported by the bed board.
C.Move the trapeze bar to allow the client to pull with the upper extremities.
D.Place trochanter rolls on the lateral aspects of the client's thighs. - ANS-D
Trochanter rolls (D) should be placed on the lateral aspects of the thighs to prevent external
rotation of the hips when the client is in a supine position. Although (A, B, and C) are
supportive equipment used to maintain proper positioning of the client who is immobile, it is
most important to maintain the lower extremities in the aligned anatomical position. A bed
board (A) provides increased back support, especially with a soft mattress. The footboard
(B) maintains the feet in dorsiflexion and prevents foot drop. The trapeze bar (C) allows the
client to participate while turning in the bed, during transfers in and out of bed, or performing
upper arm exercises.
\A client with hepatic failure tells the nurse about recent use of acetaminophen (Tylenol).
How should the nurse respond to this client's statement? - ANS-The drug is hepatotoxic and
contraindicated.
\A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish
and swallow. Which information is most important for the nurse to provide the client? -
ANS-Oral hygiene should be performed before the medication.
\A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and
lying on the floor for 24 hours before being found. Which current client finding is indicative of
renal complications? - ANS-Blood urea nitrogen >25 mg/dL
\A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence
in the Middle East is soon going to destroy the entire world!" How should the nurse respond?
