HESI exit exam 799 questions
53- A male client receives a thrombolytic medication following a myocardial
infarction. When the client has a bowel movement, what action should the nurse
implement?
a. Send stool sample to the lab for a guaiac test
b. Observe stool for a day-colored appearance.
c. Obtain specimen for culture and sensitivity analysis
d. Asses for fatty yellow streaks in the client's stool. - ANS-a. Send stool sample to
the lab for a guaiac test
\53- A male client with a long history of alcoholism is admitted because of mild
confusion and fine motor tremors. He reports that he quit drinking alcohol and
stopped smoking cigarettes one month ago after his brother died of lung cancer.
Which intervention is most important for the nurses to include in the client's plan of
care?
a. Determine client's level current blood alcohol level.
b. Observe for changes in level of consciousness.
c. Involve the client's family in healthcare decisions.
d. Provide grief counseling for client and his family. - ANS-b. Observe for changes in
level of consciousness.
\595. A client admitted to the emergency center had inspiratory and expiratory
wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the
physical examination. Based on these assessment findings, what classification of
pharmacologic agents should the nurse anticipate administering?
a. Beta blockers
b. Bronchodilators
c. Corticosteroids
d. Beta-adrenergic - ANS-b. Bronchodilators
\A 10 year old who has terminal brain cancer asks the nurse, "What will happen to
my body when I die?" How should the nurse respond?
a. "Your mother & father will be here soon. Talk to them about that."
b. "Why do you want to know about what will happen to your body when you die?"
c. "The heart will stop beating & you will stop breathing."
d. "Are you concerned about where your spirit will go?" - ANS-c. "The heart will stop
beating & you will stop breathing."
\A 12 year old client who had an appendectomy two days ago is receiving 0.9%
normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action
should the nurse implement?
a. Evaluate postural blood pressure measurements
b. Obtain specimen for uranalysis
c. Encourage popsicles and fluids of choice
,d. Assess bowel sounds in all quadrants - ANS-c. Encourage popsicles and fluids of
choice
\A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted
with osteomyelitis. The healthcare provider collects home aspirate specimens for
culture and sensitivity and applies a cast to the adolescent's lower leg. What action
should the nurse implement next?
a. Administer antiemetic agents
b. Bivalve the cast for distal compromise
c. Provide high- calorie, high-protein diet
d. Begin parenteral antibiotic therapy - ANS-d. Begin parenteral antibiotic therapy
\A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100
ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1
units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump
to Infuse how many ml/hour? enter numeric value only - ANS-7
\A 16-year-old adolescent with meningococcal meningitis is receiving a continuous
IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of
2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of
normal saline. How many ml/hr should the nurse program the infusion pump? (Enter
numeric value only. If rounding is required, round to the nearest whole number.) -
ANS-83
\A 16-year-old male is admitted to the pediatric intensive care unit after being
involved in a house fire. He has full thickness burns to his lower torso and
extremities. Before a dressing change to his legs, which intervention is most
important for the nurse to implement?
a- Encourage the parents to stay at the bedside
b- Use distraction techniques to reduce pain.
c- Maintain strict aseptic technique
d- Place a drape over the pubic area. - ANS-c- Maintain strict aseptic technique
\A 17-year -old male is brought to the emergency department by his parents because
he has been coughing and running a fever with flu-like symptoms for the past 24
hours. Which intervention should the nurse implement first?
A. Obtain a chest X-ray per protocol.
B. Place a mask on the client's face.
C. Assess the client's temperature.
D. Determine the client's blood pressure - ANS-B. Place a mask on the client's face.
\A 2-year-old girl is brought to the clinic for a routine assessment and all findings are
within the normal limits. However, the mom expresses concern over her daughter's
protruding abdomen and tells the nurse that she is worry that her child is becoming
overweight. How should the nurse respond to the mother's comment?
a- Tell the mother to keep a twenty- four-hour food diary for the child.
b- Explain that a protruding abdomen is typical for toddlers.
c- Discuss way to increase the child's daily activity level
d- Ask the mother is she has weight problems when she was a child. - ANS-b-
Explain that a protruding abdomen is typical for toddlers.
,\A 2-year-old is bleeding from a laceration on the right lower extremity that occurred
as the result of a motor vehicle collision. The nurse is selecting supplies to start an
IV access. Which assessment finding is most significant in the nurse's selection of
catheter size?
a. Thready brachial pulse.
b. Respirations of 24/minute
c. Right foot cool to touch.
d. Swelling at the site of injury - ANS-a. Thready brachial pulse.
\A 26-year-old female client is admitted to the hospital for treatment of a simple
goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate
to the nurse that the prescribed dosage is too high for this client? The client
experiences
a. Palpitations and shortness of breath
b. Bradycardia and constipation
c. Lethargy and lack of appetite
d. Muscle cramping and dry, flushed skin - ANS-a. Palpitations and shortness of
breath
\A 3-year-old boy with a congenital heart defect is brought to the clinic by his
mother... During the assessment, the mother asks the nurse why her child is at the
5th percent...response is best for the nurse to provide?
a. Does your child seem mentally slower than his peers also?
b. "His smaller size is probably due to the heart disease"
c. Haven't you been feeding him according to recommended daily allowances for
children?
d. You should not worry about the growth tables. They are only averages for children
- ANS-b. "His smaller size is probably due to the heart disease"
\A 35 years old female client has just been admitted to the post anesthesia recovery
unit following a partial thyroidectomy. Which statement reflects the nurse's accurate
understanding of the expected outcome for the client following this surgery?
a- Supplemental hormonal therapy will probably be unnecessary
b- The thyroid will regenerate to a normal size within a few years.
c- The client will be restricted from eating seafood
d- The remainder of the thyroid will be removed at a later date. - ANS-c- The client
will be restricted from eating seafood
\A 350-bed acute care hospital declares an internal disaster because the emergency
generators malfunctioned during a city-wide power failure. The UAPs working on a
general medical unit ask the charge nurse what they should do first. What instruction
should the charge nurse provide to these UAPs?
a. Go to the emergency department and complete assigned tasks
b. Shut all doors to client rooms on the unit in case a fire erupts
c. Offer to assist the ICY with ventilator-dependent clients
d. Tell all their assigned clients to stay in their rooms. - ANS-d. Tell all their assigned
clients to stay in their rooms.
, \A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy
(CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite.
Which information should the nurse provide the parents about caring for their child? -
ANS-Use sunblock or protective clothing when outdoors
\A 46-year-old male client who had a myocardial infarction 24-hours ago comes to
the nurse's station fully dressed and wanting to go home. He tells the nurse that he is
feeling much better at this time. Based on this behavior, which nursing problem
should the nurse formulate? - ANS-Ineffective coping related to denial
\A 56-years-old man shares with the nurse that he is having difficulty making
decision about terminating life support for his wife. What is the best initial action by
the nurse?
a. Provide an opportunity for him to clarify his values related to the decision
b. Encourage him to share memories about his life with his wife and family
c. Advise him to seek several opinions before making decision
d. Offer to contact the hospital chaplain or social worker to offer support. - ANS-a.
Provide an opportunity for him to clarify his values related to the decision
\A 59-year-old male client comes to the clinic and reports his concern over a lump
that, "just popped up on my neck about a week ago." In performing an examination
of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph
node. There is not overlying tissue inflammation. What do these findings suggest
A.)Malignancy
B.)Bacterial infection
C.)Viral infection
D.)Lymphangitis - ANS-A.) A.)Malignancy
\A 6 -years-old who has asthma is demonstrating a prolonged expiratory phase and
wheezing, and has 35% personal best peak expiratory flow rate (PEFR). Based on
these finding, which action should the nurse implement first?
a. Administer a prescribed bronchodilator.
b. Report finding to the healthcare provider.
c. Encourage the child to cough and deep breath
d. Determine what trigger precipitated this attack. - ANS-a. Administer a prescribed
bronchodilator.
\A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy...
Which action should the nurse instruct the parents to take if the child begins to
vomit?
a. Continue giving ORS frequently in small amounts
b. Withhold all oral intake
c. Supplement ORS with gelatin or chicken broth
d. Provide only bottle water. - ANS-a. Continue giving ORS frequently in small
amounts
\A 60-year-old female client asks the nurse about hormones replacement therapy
(HRT) as a means preventing osteoporosis. Which factor in the client's history is a
possible contraindication for the use of HRT? - ANS-Her mother and sister have a
history of breast cancer
53- A male client receives a thrombolytic medication following a myocardial
infarction. When the client has a bowel movement, what action should the nurse
implement?
a. Send stool sample to the lab for a guaiac test
b. Observe stool for a day-colored appearance.
c. Obtain specimen for culture and sensitivity analysis
d. Asses for fatty yellow streaks in the client's stool. - ANS-a. Send stool sample to
the lab for a guaiac test
\53- A male client with a long history of alcoholism is admitted because of mild
confusion and fine motor tremors. He reports that he quit drinking alcohol and
stopped smoking cigarettes one month ago after his brother died of lung cancer.
Which intervention is most important for the nurses to include in the client's plan of
care?
a. Determine client's level current blood alcohol level.
b. Observe for changes in level of consciousness.
c. Involve the client's family in healthcare decisions.
d. Provide grief counseling for client and his family. - ANS-b. Observe for changes in
level of consciousness.
\595. A client admitted to the emergency center had inspiratory and expiratory
wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the
physical examination. Based on these assessment findings, what classification of
pharmacologic agents should the nurse anticipate administering?
a. Beta blockers
b. Bronchodilators
c. Corticosteroids
d. Beta-adrenergic - ANS-b. Bronchodilators
\A 10 year old who has terminal brain cancer asks the nurse, "What will happen to
my body when I die?" How should the nurse respond?
a. "Your mother & father will be here soon. Talk to them about that."
b. "Why do you want to know about what will happen to your body when you die?"
c. "The heart will stop beating & you will stop breathing."
d. "Are you concerned about where your spirit will go?" - ANS-c. "The heart will stop
beating & you will stop breathing."
\A 12 year old client who had an appendectomy two days ago is receiving 0.9%
normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action
should the nurse implement?
a. Evaluate postural blood pressure measurements
b. Obtain specimen for uranalysis
c. Encourage popsicles and fluids of choice
,d. Assess bowel sounds in all quadrants - ANS-c. Encourage popsicles and fluids of
choice
\A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted
with osteomyelitis. The healthcare provider collects home aspirate specimens for
culture and sensitivity and applies a cast to the adolescent's lower leg. What action
should the nurse implement next?
a. Administer antiemetic agents
b. Bivalve the cast for distal compromise
c. Provide high- calorie, high-protein diet
d. Begin parenteral antibiotic therapy - ANS-d. Begin parenteral antibiotic therapy
\A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100
ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1
units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump
to Infuse how many ml/hour? enter numeric value only - ANS-7
\A 16-year-old adolescent with meningococcal meningitis is receiving a continuous
IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of
2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of
normal saline. How many ml/hr should the nurse program the infusion pump? (Enter
numeric value only. If rounding is required, round to the nearest whole number.) -
ANS-83
\A 16-year-old male is admitted to the pediatric intensive care unit after being
involved in a house fire. He has full thickness burns to his lower torso and
extremities. Before a dressing change to his legs, which intervention is most
important for the nurse to implement?
a- Encourage the parents to stay at the bedside
b- Use distraction techniques to reduce pain.
c- Maintain strict aseptic technique
d- Place a drape over the pubic area. - ANS-c- Maintain strict aseptic technique
\A 17-year -old male is brought to the emergency department by his parents because
he has been coughing and running a fever with flu-like symptoms for the past 24
hours. Which intervention should the nurse implement first?
A. Obtain a chest X-ray per protocol.
B. Place a mask on the client's face.
C. Assess the client's temperature.
D. Determine the client's blood pressure - ANS-B. Place a mask on the client's face.
\A 2-year-old girl is brought to the clinic for a routine assessment and all findings are
within the normal limits. However, the mom expresses concern over her daughter's
protruding abdomen and tells the nurse that she is worry that her child is becoming
overweight. How should the nurse respond to the mother's comment?
a- Tell the mother to keep a twenty- four-hour food diary for the child.
b- Explain that a protruding abdomen is typical for toddlers.
c- Discuss way to increase the child's daily activity level
d- Ask the mother is she has weight problems when she was a child. - ANS-b-
Explain that a protruding abdomen is typical for toddlers.
,\A 2-year-old is bleeding from a laceration on the right lower extremity that occurred
as the result of a motor vehicle collision. The nurse is selecting supplies to start an
IV access. Which assessment finding is most significant in the nurse's selection of
catheter size?
a. Thready brachial pulse.
b. Respirations of 24/minute
c. Right foot cool to touch.
d. Swelling at the site of injury - ANS-a. Thready brachial pulse.
\A 26-year-old female client is admitted to the hospital for treatment of a simple
goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate
to the nurse that the prescribed dosage is too high for this client? The client
experiences
a. Palpitations and shortness of breath
b. Bradycardia and constipation
c. Lethargy and lack of appetite
d. Muscle cramping and dry, flushed skin - ANS-a. Palpitations and shortness of
breath
\A 3-year-old boy with a congenital heart defect is brought to the clinic by his
mother... During the assessment, the mother asks the nurse why her child is at the
5th percent...response is best for the nurse to provide?
a. Does your child seem mentally slower than his peers also?
b. "His smaller size is probably due to the heart disease"
c. Haven't you been feeding him according to recommended daily allowances for
children?
d. You should not worry about the growth tables. They are only averages for children
- ANS-b. "His smaller size is probably due to the heart disease"
\A 35 years old female client has just been admitted to the post anesthesia recovery
unit following a partial thyroidectomy. Which statement reflects the nurse's accurate
understanding of the expected outcome for the client following this surgery?
a- Supplemental hormonal therapy will probably be unnecessary
b- The thyroid will regenerate to a normal size within a few years.
c- The client will be restricted from eating seafood
d- The remainder of the thyroid will be removed at a later date. - ANS-c- The client
will be restricted from eating seafood
\A 350-bed acute care hospital declares an internal disaster because the emergency
generators malfunctioned during a city-wide power failure. The UAPs working on a
general medical unit ask the charge nurse what they should do first. What instruction
should the charge nurse provide to these UAPs?
a. Go to the emergency department and complete assigned tasks
b. Shut all doors to client rooms on the unit in case a fire erupts
c. Offer to assist the ICY with ventilator-dependent clients
d. Tell all their assigned clients to stay in their rooms. - ANS-d. Tell all their assigned
clients to stay in their rooms.
, \A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy
(CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite.
Which information should the nurse provide the parents about caring for their child? -
ANS-Use sunblock or protective clothing when outdoors
\A 46-year-old male client who had a myocardial infarction 24-hours ago comes to
the nurse's station fully dressed and wanting to go home. He tells the nurse that he is
feeling much better at this time. Based on this behavior, which nursing problem
should the nurse formulate? - ANS-Ineffective coping related to denial
\A 56-years-old man shares with the nurse that he is having difficulty making
decision about terminating life support for his wife. What is the best initial action by
the nurse?
a. Provide an opportunity for him to clarify his values related to the decision
b. Encourage him to share memories about his life with his wife and family
c. Advise him to seek several opinions before making decision
d. Offer to contact the hospital chaplain or social worker to offer support. - ANS-a.
Provide an opportunity for him to clarify his values related to the decision
\A 59-year-old male client comes to the clinic and reports his concern over a lump
that, "just popped up on my neck about a week ago." In performing an examination
of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph
node. There is not overlying tissue inflammation. What do these findings suggest
A.)Malignancy
B.)Bacterial infection
C.)Viral infection
D.)Lymphangitis - ANS-A.) A.)Malignancy
\A 6 -years-old who has asthma is demonstrating a prolonged expiratory phase and
wheezing, and has 35% personal best peak expiratory flow rate (PEFR). Based on
these finding, which action should the nurse implement first?
a. Administer a prescribed bronchodilator.
b. Report finding to the healthcare provider.
c. Encourage the child to cough and deep breath
d. Determine what trigger precipitated this attack. - ANS-a. Administer a prescribed
bronchodilator.
\A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy...
Which action should the nurse instruct the parents to take if the child begins to
vomit?
a. Continue giving ORS frequently in small amounts
b. Withhold all oral intake
c. Supplement ORS with gelatin or chicken broth
d. Provide only bottle water. - ANS-a. Continue giving ORS frequently in small
amounts
\A 60-year-old female client asks the nurse about hormones replacement therapy
(HRT) as a means preventing osteoporosis. Which factor in the client's history is a
possible contraindication for the use of HRT? - ANS-Her mother and sister have a
history of breast cancer
