SPRING 2023 HESI EXIT
A male client is admitted for the removal of an internal fixation device that was
inserted for a fractured ankle. During the client's admission history, he tells the nurse
that he recently received vancomycin for a methicillin-resistant Staphylococcus
aureus (MRSA)
wound infection. Which action(s) should the nurse take? (Select all that apply.)
Collect multiple site screening cultures for MRSA.
B Place the client on contact transmission precautions.
C Call healthcare provider for a prescription for linezolid.
D Obtain a sputum specimen for culture and sensitivity.
E Continue to monitor the client for signs of an infection. - ANS-A Collect multiple
site screening cultures for MRSA.
B Place the client on contact transmission precautions.
E Continue to monitor the client for signs of an infection.
\112) An adult male client reports that he recently experienced an episode of chest
pressure and breathlessness when he was jogging. The client expresses concern
because both of his deceased parents had heart disease and his father had
diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which
maintains his blood pressure at 130/74 mm hg. Which risk factors should the nurse
explore further with the client? (SATA)
A History of hypertension.
B Homosexual lifestyle.
C Vegetarian diet.
D Excessive aerobic exercise.
E Family health history. - ANS-A History of hypertension.
E Family health history.
\129) A client with obstructive sleep apnea (OSA) ambulates in the hallway with the
nurse prior to bedtime and intervention is most important for the nurse to implement
before leaving the client?
A. Apply the client's positive airway pressure device.
B Elevate the head of the bed to a 45 degree angle.
C Lift and lock the side rails in place.
D Remove dentures or other oral appliance. - ANS-A. Apply the client's positive
airway pressure device.
\A 46-year-old male client who had a myocardial infarction (MI) 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 client problem
should the nurse included in the plan of care?
,A Anxiety related to treatment plan.
B Decisional conflict due to stress.
C Deficient knowledge of lifestyle changes.
D. Ineffective coping related to denial. - ANS-D. Ineffective coping related to denial.
\A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which
pre-operative nursing action has the highest priority?
A Instruct parents regarding care of the incisional area.
B Mark an outline of the "olive-Shaped" mass in the right epigastric area.
C Initiate a continuous infusion of IV fluids per prescription.
D Monitor amount of intake and infant's response to feedings. - ANS-C Initiate a
continuous infusion of IV fluids per prescription.
\A child with peripheral edema who weighs 44 pounds receives a prescription for
furosemide 2 mg/kg intravenously every 12 hours. The vial is labeled, "10 mg/mL."
How many mL should the nurse administer? (Enter numeric value only.) - ANS-4 mL
\A client exposed to tuberculosis is scheduled to begin prophylactic treatment with
isoniazid. Which information is most important for the nurse to note before
administering the initial dose?
A Current diagnosis of hepatitis B.
B History of intravenous drug abuse.
C Length of time of the exposure to tuberculosis.
D Conversion of the client's PPD test from negative to positive. - ANS-A Current
diagnosis of hepatitis B.
\A client is admitted to the hospital after experiencing a stroke or cerebrovascular
accident (CVA). The nurse should request a referral for speech therapy if the client
exhibits which finding?
A Inappropriate or exaggerated mood swings.
B Persistent coughing while drinking.
C Abnormal responses for cranial nerves I and Il.
D Unilateral facial drooping. - ANS-B Persistent coughing while drinking.
\A client is being discharged with a prescription for warfarin. Which instruction should
the nurse provide this client regarding diet?
A Avoid eating all foods that contain any vitamin K because it is an antagonist of
warfarin.
B Increase the intake of dark green leafy vegetables while taking warfarin.
C Eat approximately the same amount of leafy green vegetables daily so the amount
of vitamin K consumed is consistent.
D Eat two servings of raw dark green leafy vegetables daily and continue for 30 days
after warfarin therapy is completed. - ANS-C Eat approximately the same amount of
leafy green vegetables daily so the amount of vitamin K consumed is consistent.
, \A client is being urgently transported to radiology for a Computerized Tomography
(CT scan) after a sudden decrease in level of consciousness. The client is orally
intubated and has a left lateral chest tube to 20 cm suction. Which action is most
important for the nurse to take?
A Secure chest tube to the stretcher for transport.
B Administer PRN pain medication prior to transport.
C Keep chest tube container below the site of insertion.
D Mark the amount of chest drainage on the container. - ANS-C Keep chest tube
container below the site of insertion.
\A client is receiving continuous ambulatory peritoneal dialysis since the
arteriovenous (AV) graft in the right arm is no longer available to use for
hemodialysis. The client has lost weight, has increasing peripheral edema, and has a
serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the
nurse to implement?
Reference Range:
Serum Albumin [Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)].
A Evaluate patency of the AV graft for resumption of hemodialysis.
B Ensure the client receives frequent small meals containing complete proteins.
C Instruct the client to continue to follow the prescribed rigid fluid restriction amounts.
D Recommend the use of support stockings to enhance venous return. - ANS-B
Ensure the client receives frequent small meals containing complete proteins.
\A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the
client's therapeutic response to this medication, which assessment should the nurse
obtain?
A Blood glucose level.
B Percussion of abdomen.
C Serum electrolytes.
D Level of consciousness. - ANS-D Level of consciousness.
\A client is unable to void following a procedure, so the nurse obtains a prescription
to perform a straight catheterization. After inserting the catheter, the nurse observes
that the client has an immediate output of 500 mL of clear yellow urine. Which action
should the nurse implement next?
A Remove the catheter and palpate the client's bladder for residual distention.
B Clamp the catheter for thirty minutes and then resume draining.
C Remove the catheter and replace it with an indwelling catheter.
D Allow the bladder to empty completely or up to 1,000 mL of urine. - ANS-D Allow
the bladder to empty completely or up to 1,000 mL of urine.
A male client is admitted for the removal of an internal fixation device that was
inserted for a fractured ankle. During the client's admission history, he tells the nurse
that he recently received vancomycin for a methicillin-resistant Staphylococcus
aureus (MRSA)
wound infection. Which action(s) should the nurse take? (Select all that apply.)
Collect multiple site screening cultures for MRSA.
B Place the client on contact transmission precautions.
C Call healthcare provider for a prescription for linezolid.
D Obtain a sputum specimen for culture and sensitivity.
E Continue to monitor the client for signs of an infection. - ANS-A Collect multiple
site screening cultures for MRSA.
B Place the client on contact transmission precautions.
E Continue to monitor the client for signs of an infection.
\112) An adult male client reports that he recently experienced an episode of chest
pressure and breathlessness when he was jogging. The client expresses concern
because both of his deceased parents had heart disease and his father had
diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which
maintains his blood pressure at 130/74 mm hg. Which risk factors should the nurse
explore further with the client? (SATA)
A History of hypertension.
B Homosexual lifestyle.
C Vegetarian diet.
D Excessive aerobic exercise.
E Family health history. - ANS-A History of hypertension.
E Family health history.
\129) A client with obstructive sleep apnea (OSA) ambulates in the hallway with the
nurse prior to bedtime and intervention is most important for the nurse to implement
before leaving the client?
A. Apply the client's positive airway pressure device.
B Elevate the head of the bed to a 45 degree angle.
C Lift and lock the side rails in place.
D Remove dentures or other oral appliance. - ANS-A. Apply the client's positive
airway pressure device.
\A 46-year-old male client who had a myocardial infarction (MI) 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 client problem
should the nurse included in the plan of care?
,A Anxiety related to treatment plan.
B Decisional conflict due to stress.
C Deficient knowledge of lifestyle changes.
D. Ineffective coping related to denial. - ANS-D. Ineffective coping related to denial.
\A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which
pre-operative nursing action has the highest priority?
A Instruct parents regarding care of the incisional area.
B Mark an outline of the "olive-Shaped" mass in the right epigastric area.
C Initiate a continuous infusion of IV fluids per prescription.
D Monitor amount of intake and infant's response to feedings. - ANS-C Initiate a
continuous infusion of IV fluids per prescription.
\A child with peripheral edema who weighs 44 pounds receives a prescription for
furosemide 2 mg/kg intravenously every 12 hours. The vial is labeled, "10 mg/mL."
How many mL should the nurse administer? (Enter numeric value only.) - ANS-4 mL
\A client exposed to tuberculosis is scheduled to begin prophylactic treatment with
isoniazid. Which information is most important for the nurse to note before
administering the initial dose?
A Current diagnosis of hepatitis B.
B History of intravenous drug abuse.
C Length of time of the exposure to tuberculosis.
D Conversion of the client's PPD test from negative to positive. - ANS-A Current
diagnosis of hepatitis B.
\A client is admitted to the hospital after experiencing a stroke or cerebrovascular
accident (CVA). The nurse should request a referral for speech therapy if the client
exhibits which finding?
A Inappropriate or exaggerated mood swings.
B Persistent coughing while drinking.
C Abnormal responses for cranial nerves I and Il.
D Unilateral facial drooping. - ANS-B Persistent coughing while drinking.
\A client is being discharged with a prescription for warfarin. Which instruction should
the nurse provide this client regarding diet?
A Avoid eating all foods that contain any vitamin K because it is an antagonist of
warfarin.
B Increase the intake of dark green leafy vegetables while taking warfarin.
C Eat approximately the same amount of leafy green vegetables daily so the amount
of vitamin K consumed is consistent.
D Eat two servings of raw dark green leafy vegetables daily and continue for 30 days
after warfarin therapy is completed. - ANS-C Eat approximately the same amount of
leafy green vegetables daily so the amount of vitamin K consumed is consistent.
, \A client is being urgently transported to radiology for a Computerized Tomography
(CT scan) after a sudden decrease in level of consciousness. The client is orally
intubated and has a left lateral chest tube to 20 cm suction. Which action is most
important for the nurse to take?
A Secure chest tube to the stretcher for transport.
B Administer PRN pain medication prior to transport.
C Keep chest tube container below the site of insertion.
D Mark the amount of chest drainage on the container. - ANS-C Keep chest tube
container below the site of insertion.
\A client is receiving continuous ambulatory peritoneal dialysis since the
arteriovenous (AV) graft in the right arm is no longer available to use for
hemodialysis. The client has lost weight, has increasing peripheral edema, and has a
serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the
nurse to implement?
Reference Range:
Serum Albumin [Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)].
A Evaluate patency of the AV graft for resumption of hemodialysis.
B Ensure the client receives frequent small meals containing complete proteins.
C Instruct the client to continue to follow the prescribed rigid fluid restriction amounts.
D Recommend the use of support stockings to enhance venous return. - ANS-B
Ensure the client receives frequent small meals containing complete proteins.
\A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the
client's therapeutic response to this medication, which assessment should the nurse
obtain?
A Blood glucose level.
B Percussion of abdomen.
C Serum electrolytes.
D Level of consciousness. - ANS-D Level of consciousness.
\A client is unable to void following a procedure, so the nurse obtains a prescription
to perform a straight catheterization. After inserting the catheter, the nurse observes
that the client has an immediate output of 500 mL of clear yellow urine. Which action
should the nurse implement next?
A Remove the catheter and palpate the client's bladder for residual distention.
B Clamp the catheter for thirty minutes and then resume draining.
C Remove the catheter and replace it with an indwelling catheter.
D Allow the bladder to empty completely or up to 1,000 mL of urine. - ANS-D Allow
the bladder to empty completely or up to 1,000 mL of urine.
