3/29/25, 8:21 366 EXIT HESI |
AM
366 EXIT HESI EXAM QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS
VERIFIED
Terms in this set (125)
A newly admitted client complains of pain Correct Answer:
rating a 7 on a scale of 0 to 10. The client 1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy.
has not been sleeping well lately and is Rationale
experiencing labored breathing. List the
client's problems in order of priority for the First-level problems are immediate priorities (airway, breathing, and circulation). In
nurse. (Rank in the priority order from this scenario, airway and breathing are the first priority, followed by pain
highest to lowest.) management, Maslow's hierarchy of basic needs for rest and sleep, and then
1. definitive drug therapies.
Airway and breathing.
2.
Pain management.
3.
Definitive therapy.
4.
Sleep and rest.
Which biological practices are 3. Blood-borne pathogen standard.
federally regulated for healthcare 5. Resource Conservation and Recovery Act (RCRA)
workers? (Select all that apply.)
Select all that apply Basic standards for healthcare workers, as delineated by Occupational Safety and
Health Administration (OSHA), include standard precautions, droplet precautions
1. Standard precautions. using N-95 respiratory particulate masks when caring for a client who is positive for
2. N-95 tuberculosis standard. tuberculosis, and required annual updates for healthcare workers about blood-
3. Blood-borne pathogen standard. borne pathogen transmission, methods of minimizing exposure, and employee
4. Biological product exposure limit (BPEL). rights. Other options [BPEL and ALARA ] are not federally regulated.
5. Resource Conservation and Recovery
Act (RCRA).
6. As Low as Reasonably
Allowable standard (ALARA).
A client with severe depression tells the 3. "I have known many clients with depression who have felt better after several
nurse, "I do not know why you bother with weeks of treatment."
me or give me pills. I am never going to
get well." What is the most therapeutic Stating the observation that others have recovered can give a client hope. Telling a
response? person to stop negtive thinking is ineffective because the client must be taught
1. "You need to stop thinking cognitive strategies to stop negative thinking. Stating the person is "no bother" is
negative thoughts. They get in the arguing with the client's beliefs and attempting to tell him how to feel, both of
way of your recovery." which are not therapeutic responses. Bring up pessimistic feelings interprets the
2."You are no bother to me or to the client's feelings and does not provide the same degree of hope.
staff. We want you to get well and not
feel sad anymore."
3. "I have known many clients
with depression who have felt better
after several weeks of treatment."
4. "You are feeling very pessimistic, but
that is part of your illness. It should go
away as you recover."
1/28
,3/29/25, 8:21 366 EXIT HESI |
AM
The nurse is caring for a client with a 3. Assess and document skin condition around the incision and IV site at each shift.
nursing problem of, "Infection, risk for,
related to inadequate primary defenses as Early identification of infection leads to prompt treatment and decreased
evidenced by surgical incision and IV nosocomial transmission to others, so the condition of any invasive lines or breaks
access." What nursing intervention should in the skin should be assessed and documented during each shift.
the nurse implement?
1. Limit visitors to immediate
family to decrease exposure to
infection.
2.Maintain "clean" technique in the change
of wound dressing and IV site.
3.Assess and document skin condition
around the incision and IV site at each
shift.
4. Require the use of a face mask by
staff when providing care requiring
close contact.
A client with ulcerative colitis is 4. Stool is eventually expelled through the rectum.
scheduled for surgical creation of an
ileoanal reservoir (J pouch). As part of
preoperative teaching, what information An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created
should the nurse provide? ileoanal reservoir in the anal canal that preserves the rectal sphincter muscle, so
1. The transverse loop ostomy is that passage of stool through the rectum is the eventual result. To promote healing
permanent. of the anastomosed parts of the colon, a temporary loop ostomy is created, not
2.Easily removable appliances allow a permanent one. Although appliances that are easy to use are advantageous, the
independence in self-care. ostomy is reversed after healing takes place. Stool drains into the reservoir, so daily
3.Daily irrigation is started after the J irrigation is not usually indicated.
pouch heals.
4. Stool is eventually expelled through the
rectum.
2/28
, 3/29/25, 8:21 366 EXIT HESI |
AM
The nurse inflates the cuff on a 4. Inject air until no air is auscultated over the larynx during a deep breath.
tracheostomy tube to minimal occlusion
pressure for a client who is breathing To achieve minimal pressure (minimal occlusion volume technique) against the
spontaneously. Which action should the tracheal wall, inject air into the tracheostomy tube cuff while auscultating with a
nurse follow? stethoscope placed over the larynx (over the cuff) during inhalation. At the point
1. Check the pilot balloon to ensure when sounds of air movement cease, inflation is stopped, indicating that the cuff is
that it is firm. sealed against the tracheal wall.
2.Verify the healthcare provider's
prescription for the required cuff
pressure.
3.Use a manometer to maintain
cuff pressure between 25 and 30
mmHg.
4. Inject air until no air is auscultated
over the larynx during a deep breath.
A 60-year-old homeless man who 1. Refer for further diagnostic evaluation.
complains of a cough, late-afternoon fever,
and night sweats has a 10 mm induration The PPD skin test results is indicative of exposure or latent Mycobacterium
after receiving a purified protein derivative tuberculosis infection (LTBI), which this client is in a high-risk category for exposure in
(PPD) skin test. Which action should the a homeless environment. Although productive prolonged cough, fever, and night
nurse implement? sweats are common early symptoms, persons suspected of LTBI should not
1. Refer for further diagnostic begin treatment until active TB disease has been excluded. Further diagnostic
evaluation. evaluation should be implemented. A dormant form that neither causes disease nor
2.Determine exposure of others to the is communicable.
tuberculosis.
3.Begin anti-tubercular drug therapy.
4.Quarantine or isolate to control
communicability.
1. Economics.
Which contextual factors are considered
3. Technology.
external environmental influences in the
6. Legislation/regulation.
framework for occupational health
programs and services? (Select all
Economics affects the health of the company and its workforce productivity, in
that apply.)
termsof profitability, growth, and expansion. Technology adds to an industry's
Select all that apply
capacity to develop and implement new or improved work processes.
1. Economics.
Legislation/regulation in the workplace, such as the blood-borne pathogen
2.Workforce.
standard, affects the workforce in terms of requirements, administration, and control
3.Technology.
strategies. Occupational safety programs are built around the workforce to strive for
4. Interventions.
maximum internal productivity. Interventions are internal environmental influences of
5. Socio-economic status.
an occupational health and safety program. Socio-economic status is a demographic
6.Legislation/regulation.
variable commonly used in epidemiology.
The nurse is analyzing the waveforms of 4. QRS interval of 0.14 second.
a client's electrocardiogram. What
finding indicates a disturbance in The normal duration of the QRS is 0.04 to 0.12 second, so a prolonged QRS
electrical conduction in the indicates an electrical anomaly in the ventricles. The T wave is normally 0.16
ventricles? seconds. The PR interval range is 0.12 to 0.20 second. The QT interval should be
1. T wave of 0.16 second. 0.31 to 0.38 second.
2.PR interval of 0.18 second.
3.QT interval of 0.34 second.
4.QRS interval of 0.14 second.
3/28
AM
366 EXIT HESI EXAM QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS
VERIFIED
Terms in this set (125)
A newly admitted client complains of pain Correct Answer:
rating a 7 on a scale of 0 to 10. The client 1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy.
has not been sleeping well lately and is Rationale
experiencing labored breathing. List the
client's problems in order of priority for the First-level problems are immediate priorities (airway, breathing, and circulation). In
nurse. (Rank in the priority order from this scenario, airway and breathing are the first priority, followed by pain
highest to lowest.) management, Maslow's hierarchy of basic needs for rest and sleep, and then
1. definitive drug therapies.
Airway and breathing.
2.
Pain management.
3.
Definitive therapy.
4.
Sleep and rest.
Which biological practices are 3. Blood-borne pathogen standard.
federally regulated for healthcare 5. Resource Conservation and Recovery Act (RCRA)
workers? (Select all that apply.)
Select all that apply Basic standards for healthcare workers, as delineated by Occupational Safety and
Health Administration (OSHA), include standard precautions, droplet precautions
1. Standard precautions. using N-95 respiratory particulate masks when caring for a client who is positive for
2. N-95 tuberculosis standard. tuberculosis, and required annual updates for healthcare workers about blood-
3. Blood-borne pathogen standard. borne pathogen transmission, methods of minimizing exposure, and employee
4. Biological product exposure limit (BPEL). rights. Other options [BPEL and ALARA ] are not federally regulated.
5. Resource Conservation and Recovery
Act (RCRA).
6. As Low as Reasonably
Allowable standard (ALARA).
A client with severe depression tells the 3. "I have known many clients with depression who have felt better after several
nurse, "I do not know why you bother with weeks of treatment."
me or give me pills. I am never going to
get well." What is the most therapeutic Stating the observation that others have recovered can give a client hope. Telling a
response? person to stop negtive thinking is ineffective because the client must be taught
1. "You need to stop thinking cognitive strategies to stop negative thinking. Stating the person is "no bother" is
negative thoughts. They get in the arguing with the client's beliefs and attempting to tell him how to feel, both of
way of your recovery." which are not therapeutic responses. Bring up pessimistic feelings interprets the
2."You are no bother to me or to the client's feelings and does not provide the same degree of hope.
staff. We want you to get well and not
feel sad anymore."
3. "I have known many clients
with depression who have felt better
after several weeks of treatment."
4. "You are feeling very pessimistic, but
that is part of your illness. It should go
away as you recover."
1/28
,3/29/25, 8:21 366 EXIT HESI |
AM
The nurse is caring for a client with a 3. Assess and document skin condition around the incision and IV site at each shift.
nursing problem of, "Infection, risk for,
related to inadequate primary defenses as Early identification of infection leads to prompt treatment and decreased
evidenced by surgical incision and IV nosocomial transmission to others, so the condition of any invasive lines or breaks
access." What nursing intervention should in the skin should be assessed and documented during each shift.
the nurse implement?
1. Limit visitors to immediate
family to decrease exposure to
infection.
2.Maintain "clean" technique in the change
of wound dressing and IV site.
3.Assess and document skin condition
around the incision and IV site at each
shift.
4. Require the use of a face mask by
staff when providing care requiring
close contact.
A client with ulcerative colitis is 4. Stool is eventually expelled through the rectum.
scheduled for surgical creation of an
ileoanal reservoir (J pouch). As part of
preoperative teaching, what information An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created
should the nurse provide? ileoanal reservoir in the anal canal that preserves the rectal sphincter muscle, so
1. The transverse loop ostomy is that passage of stool through the rectum is the eventual result. To promote healing
permanent. of the anastomosed parts of the colon, a temporary loop ostomy is created, not
2.Easily removable appliances allow a permanent one. Although appliances that are easy to use are advantageous, the
independence in self-care. ostomy is reversed after healing takes place. Stool drains into the reservoir, so daily
3.Daily irrigation is started after the J irrigation is not usually indicated.
pouch heals.
4. Stool is eventually expelled through the
rectum.
2/28
, 3/29/25, 8:21 366 EXIT HESI |
AM
The nurse inflates the cuff on a 4. Inject air until no air is auscultated over the larynx during a deep breath.
tracheostomy tube to minimal occlusion
pressure for a client who is breathing To achieve minimal pressure (minimal occlusion volume technique) against the
spontaneously. Which action should the tracheal wall, inject air into the tracheostomy tube cuff while auscultating with a
nurse follow? stethoscope placed over the larynx (over the cuff) during inhalation. At the point
1. Check the pilot balloon to ensure when sounds of air movement cease, inflation is stopped, indicating that the cuff is
that it is firm. sealed against the tracheal wall.
2.Verify the healthcare provider's
prescription for the required cuff
pressure.
3.Use a manometer to maintain
cuff pressure between 25 and 30
mmHg.
4. Inject air until no air is auscultated
over the larynx during a deep breath.
A 60-year-old homeless man who 1. Refer for further diagnostic evaluation.
complains of a cough, late-afternoon fever,
and night sweats has a 10 mm induration The PPD skin test results is indicative of exposure or latent Mycobacterium
after receiving a purified protein derivative tuberculosis infection (LTBI), which this client is in a high-risk category for exposure in
(PPD) skin test. Which action should the a homeless environment. Although productive prolonged cough, fever, and night
nurse implement? sweats are common early symptoms, persons suspected of LTBI should not
1. Refer for further diagnostic begin treatment until active TB disease has been excluded. Further diagnostic
evaluation. evaluation should be implemented. A dormant form that neither causes disease nor
2.Determine exposure of others to the is communicable.
tuberculosis.
3.Begin anti-tubercular drug therapy.
4.Quarantine or isolate to control
communicability.
1. Economics.
Which contextual factors are considered
3. Technology.
external environmental influences in the
6. Legislation/regulation.
framework for occupational health
programs and services? (Select all
Economics affects the health of the company and its workforce productivity, in
that apply.)
termsof profitability, growth, and expansion. Technology adds to an industry's
Select all that apply
capacity to develop and implement new or improved work processes.
1. Economics.
Legislation/regulation in the workplace, such as the blood-borne pathogen
2.Workforce.
standard, affects the workforce in terms of requirements, administration, and control
3.Technology.
strategies. Occupational safety programs are built around the workforce to strive for
4. Interventions.
maximum internal productivity. Interventions are internal environmental influences of
5. Socio-economic status.
an occupational health and safety program. Socio-economic status is a demographic
6.Legislation/regulation.
variable commonly used in epidemiology.
The nurse is analyzing the waveforms of 4. QRS interval of 0.14 second.
a client's electrocardiogram. What
finding indicates a disturbance in The normal duration of the QRS is 0.04 to 0.12 second, so a prolonged QRS
electrical conduction in the indicates an electrical anomaly in the ventricles. The T wave is normally 0.16
ventricles? seconds. The PR interval range is 0.12 to 0.20 second. The QT interval should be
1. T wave of 0.16 second. 0.31 to 0.38 second.
2.PR interval of 0.18 second.
3.QT interval of 0.34 second.
4.QRS interval of 0.14 second.
3/28
