HESI EXIT VERSION 3 EXIT EXAM RN SCHOOL
m m m m m m m
1. Themnursemismreviewingmmedicalmprescriptionsmfor mnewlymadmitted mclients.m It mwou
ld mbemamprioritym formthemnursemtomfollow mupmwithmthemphysicianmif mamclient mwith
(a) ampotassiummlevelmof m4.5mEq/LmhasmKayexalatem(sodiummpolystyrene)mprescribed
(b) amDilantinm(phenytoin)mlevelmof m8mmcg/mlmismplaced monmseizuremprecautions(c)mse
nsitivitymtomAspirinm(acetylsalicylicmacid)mismprescribed mTylenol m(acetaminophen)
(d)msensitivitymtomPenicillinmismprescribed mZithromaxm(azithromycin)
2. Themnursemshould mintervenem if mthemnursemnotesmamstaff mmember
(a) obtainingmamclientsmconsent mpriormtomtheirmoperativemproceduremaftermreceivingmAtiv
anm(lorazepam)
(b) placingmamclient monmthemaffected msidemfollowingmsurgicalmrepairmof mamretin
almdetachment
(c) handlingmamwet mcast mwithmthempalmsmof mthemhands
(d) usingmambroad mbasemof msupport mwhilemtransferringmamclient
3. Themcommunitymhealthmnursemismcaringmformthemfollowingmclients.m It mwould mbema
prioritym formthemnursemtominitiatemammultidisciplinarymconferencemformthemclient mwhomis
(a) 12myearsmold mwithmAutismmwhomismstartingmamnew mschoolmand mrecentlymha
d mamURI m(uppermrespiratorymtract minfection)
(b) 16myearsmold,mhasmtypem1mDiabetesmMellitus,mismunemployed mand mhad mamrec
ent mHemoglobinmA1cmof m13%
(c) 52myearsmold,mwithmMyastheniamGravis,mrecentlymprescribed mMestino
nm(pyridostigmine)mand memployed masmammailmcarrier
(d) 70myearsmold,mhasmschizophrenia,mlivesmalonemand mreportsmhearingmnonmthreateni
ngmvoices.
4. Themnursemfrommthempostpartummunit mhasmbeenmtemporarilymassigned mtomthemmedic
almsurgicalmunit.m It mwould mbemmostm appropriatem tomassignmthismnursemtomthemclient mwh
o*
(a) hasmreturned mfrommright mtotalmhipmreplacement msurgerymfourmhoursmago
(b) ismbeingmobserved mformincreased mintracranialmpressure
(c) had msurgerymtwomhoursmagomtomremovemthemappendix
(d) ismtwomweeksmpost mpartummbeingmmaintained monmammechanicalmventilatormf
ormrespiratorymfailure
1
,5. Themnurseminmamwellmbabymclinic mhasmassessed mseveralmchildrenmtoday.mIt mwould mbe
a prioritym formthemnursemtomsuggest mfollow mupmformthemchild mwhomism(a)m2mmonthsmold m
m m
withmampositivembabinskimreflmex
(b) 5mmonthsmold mand mdoesmnot mhold mtheirmownmbottle
(c) 10mmonthsmold mwhomcriesmaround mstrangers
(d) 18mmonthsmold mwhomneedsmsupport mwhilemambulating
6. Themnursem ismcaringmformammechanicallymventilated mclient mwhomwasmdeclared mbra
inmdead.mAnmAdvancemDirectivemismnot mdocumented monmthemmedicalmrecord.mIt mwou
ld mbemmostm appropriatem tomobtainmconsent mformorganmdonationmfrommthe
(a) client’smprimarymcaremprovider
(b) client’smnursemmanager
(c) closest mlivingmfamilymmember
(d) hospital’smethicsmcommittee
7. Themnursemhasmreceived mreport monmfourmclients.m Themnursemshould mfim rstm assessmt
hemclient mwhomhas*
(a) ChronicmObstructivemPulmonarymDiseasem(COPD)mwithmampulsemoximetrymreadingm
of m90%
(b) Parkinson’smDiseasemand mismdemandingmtomleavemthemhospitalmagainst mmedicalmadvi
cem(AMA)
(c) beenmadmitted mwithmsuspected mGuillian-
Barre´mSyndromemand mhasmbegunmplasmapheresismtherapy
(d) CongestivemHeart mFailurem(CHF)mwhosempittingmedemamhasmincreased mtom2(+)
8. It mwould mbemappropriatem tomassignmwhichmof mthesemtasksmtomthemCNA?
(a) Feedingmamclient mwhomismexperiencingmdysphagia
(b) One-on-onemclient mobservationmformsafety
(c) Removalmof manmindwellingmcatheter
(d) Performingmamsimplemdressingmchange
9. Themnursemshould mintervenem if mamstaff mmembermismobserved
(a) discussingmamclient’smdiagnosismwithmvisitingmfamilymmembers
(b) collaboratingmwithmanothermnursemtomreview mamprescriptionmformblood mtransfusion
(c) interruptingmothermstaff mmembersmdiscussingmamclient minmthemcafeteria
(d) reviewingmamclientsmlabmvaluesmwithmthemnutritionist
2
,10. Themnursemismpreparingmamstaff mpresentationmonmlegalmand methicalmissuesminmnursi
ng.mThemnursemwould mbemcorrectm tomincludemwhichmof mthemfollowingmexamples?
(a) Puttingmamclient minmamgeriatricmchairmwithmthemlapmtrayminmfront mof mthemclient minmthem
daymroommtomwatchmtelevisionmismfalsemimprisonment
(b) Tellingmamclient mthat myoumwillmput minmamfeedingmtubemif mthemclient mdoesmnot meat mis
anmexamplemof mbattery
m
(c) Tellingmamclient mwithmbipolarmdisordermwhomismsuicidalmthat mtheymhavemamright mtomref
usemtomtakemtheirmmedicationsmismanmexamplemof mmalpractice
(d) Placingmhandsmonmamclient mwhomsaysm“domnot mtouchmme”mismanmexamplemof massault
11. Themnursemfrommthempediatricmunit mhasmbeenmtemporarilymassigned mtomthemEmergen
cymDepartment.mIt mwould mbemmostm appropriatem tomassignmthat mnursemtomthemclient mwho
*
(a) reportsmepigastricmpainmthat m“feelsmlikemindigestion”
(b) hasmbackmpainmand mampulsatingmabdominalmmass
(c) ismHIV+mreportingmvomitingmand mdiarrhea
(d) presentsmwithmlowermabdominalmpainmand mismsixmweeksmpregnant
12. Fourmclientsmrecentlymreturned mtomthemunit mfollowingminvasivemdiagnosticmtesting.m T
hemnursemshould mimmediatelymintervenem if monemof mthemclients
(a) reportsmblood mtinged msputummfollowingmambronchoscopy
(b) hasmdecreased mabdominalmgirthmfollowingmparacentesis
(c) reportsmamheadachemfollowingmamlumbarmpuncture
(d) ismobserved mflexingmand mextendingmthemlegsmtwomhoursmaftermcardiacmcatheterization
13. Themnursemismmademawaremof mthemfollowingmsituations.m Themnursemshould mfim rstmche
ckmthemclient mwho
(a) had mamtransurethralmprostatectomym(TURP)mand mismreportingmurinarymdribblingmt
womhoursmaftermthemindwellingmcathetermismremoved
(b) hasmcervicalmtractionmand mismmovingmthemlegsmbymflmexingmand mextendingmthemfeet
(c) hasmAlzheimer’smdiseasem(stagem1)mand mwasmreturned mtomthemroommaftermbeingmfou
nd mwanderingminmthemhallway
(d) hasmamhistorymof mpartialmseizuresmand mismsittingminmthembed mpickingmat mthemclothingma
nd msmackingmthemlips
14. Themnurseminmamcommunitymhealthmclinicmismtalkingmwithmthemparent mof mamchild mw
ithmCeliacmDisease.m Whichmof mthemfollowingmstatementsmwould mrequirem follow-
3
, upm bymthe
4
m m m m m m m
1. Themnursemismreviewingmmedicalmprescriptionsmfor mnewlymadmitted mclients.m It mwou
ld mbemamprioritym formthemnursemtomfollow mupmwithmthemphysicianmif mamclient mwith
(a) ampotassiummlevelmof m4.5mEq/LmhasmKayexalatem(sodiummpolystyrene)mprescribed
(b) amDilantinm(phenytoin)mlevelmof m8mmcg/mlmismplaced monmseizuremprecautions(c)mse
nsitivitymtomAspirinm(acetylsalicylicmacid)mismprescribed mTylenol m(acetaminophen)
(d)msensitivitymtomPenicillinmismprescribed mZithromaxm(azithromycin)
2. Themnursemshould mintervenem if mthemnursemnotesmamstaff mmember
(a) obtainingmamclientsmconsent mpriormtomtheirmoperativemproceduremaftermreceivingmAtiv
anm(lorazepam)
(b) placingmamclient monmthemaffected msidemfollowingmsurgicalmrepairmof mamretin
almdetachment
(c) handlingmamwet mcast mwithmthempalmsmof mthemhands
(d) usingmambroad mbasemof msupport mwhilemtransferringmamclient
3. Themcommunitymhealthmnursemismcaringmformthemfollowingmclients.m It mwould mbema
prioritym formthemnursemtominitiatemammultidisciplinarymconferencemformthemclient mwhomis
(a) 12myearsmold mwithmAutismmwhomismstartingmamnew mschoolmand mrecentlymha
d mamURI m(uppermrespiratorymtract minfection)
(b) 16myearsmold,mhasmtypem1mDiabetesmMellitus,mismunemployed mand mhad mamrec
ent mHemoglobinmA1cmof m13%
(c) 52myearsmold,mwithmMyastheniamGravis,mrecentlymprescribed mMestino
nm(pyridostigmine)mand memployed masmammailmcarrier
(d) 70myearsmold,mhasmschizophrenia,mlivesmalonemand mreportsmhearingmnonmthreateni
ngmvoices.
4. Themnursemfrommthempostpartummunit mhasmbeenmtemporarilymassigned mtomthemmedic
almsurgicalmunit.m It mwould mbemmostm appropriatem tomassignmthismnursemtomthemclient mwh
o*
(a) hasmreturned mfrommright mtotalmhipmreplacement msurgerymfourmhoursmago
(b) ismbeingmobserved mformincreased mintracranialmpressure
(c) had msurgerymtwomhoursmagomtomremovemthemappendix
(d) ismtwomweeksmpost mpartummbeingmmaintained monmammechanicalmventilatormf
ormrespiratorymfailure
1
,5. Themnurseminmamwellmbabymclinic mhasmassessed mseveralmchildrenmtoday.mIt mwould mbe
a prioritym formthemnursemtomsuggest mfollow mupmformthemchild mwhomism(a)m2mmonthsmold m
m m
withmampositivembabinskimreflmex
(b) 5mmonthsmold mand mdoesmnot mhold mtheirmownmbottle
(c) 10mmonthsmold mwhomcriesmaround mstrangers
(d) 18mmonthsmold mwhomneedsmsupport mwhilemambulating
6. Themnursem ismcaringmformammechanicallymventilated mclient mwhomwasmdeclared mbra
inmdead.mAnmAdvancemDirectivemismnot mdocumented monmthemmedicalmrecord.mIt mwou
ld mbemmostm appropriatem tomobtainmconsent mformorganmdonationmfrommthe
(a) client’smprimarymcaremprovider
(b) client’smnursemmanager
(c) closest mlivingmfamilymmember
(d) hospital’smethicsmcommittee
7. Themnursemhasmreceived mreport monmfourmclients.m Themnursemshould mfim rstm assessmt
hemclient mwhomhas*
(a) ChronicmObstructivemPulmonarymDiseasem(COPD)mwithmampulsemoximetrymreadingm
of m90%
(b) Parkinson’smDiseasemand mismdemandingmtomleavemthemhospitalmagainst mmedicalmadvi
cem(AMA)
(c) beenmadmitted mwithmsuspected mGuillian-
Barre´mSyndromemand mhasmbegunmplasmapheresismtherapy
(d) CongestivemHeart mFailurem(CHF)mwhosempittingmedemamhasmincreased mtom2(+)
8. It mwould mbemappropriatem tomassignmwhichmof mthesemtasksmtomthemCNA?
(a) Feedingmamclient mwhomismexperiencingmdysphagia
(b) One-on-onemclient mobservationmformsafety
(c) Removalmof manmindwellingmcatheter
(d) Performingmamsimplemdressingmchange
9. Themnursemshould mintervenem if mamstaff mmembermismobserved
(a) discussingmamclient’smdiagnosismwithmvisitingmfamilymmembers
(b) collaboratingmwithmanothermnursemtomreview mamprescriptionmformblood mtransfusion
(c) interruptingmothermstaff mmembersmdiscussingmamclient minmthemcafeteria
(d) reviewingmamclientsmlabmvaluesmwithmthemnutritionist
2
,10. Themnursemismpreparingmamstaff mpresentationmonmlegalmand methicalmissuesminmnursi
ng.mThemnursemwould mbemcorrectm tomincludemwhichmof mthemfollowingmexamples?
(a) Puttingmamclient minmamgeriatricmchairmwithmthemlapmtrayminmfront mof mthemclient minmthem
daymroommtomwatchmtelevisionmismfalsemimprisonment
(b) Tellingmamclient mthat myoumwillmput minmamfeedingmtubemif mthemclient mdoesmnot meat mis
anmexamplemof mbattery
m
(c) Tellingmamclient mwithmbipolarmdisordermwhomismsuicidalmthat mtheymhavemamright mtomref
usemtomtakemtheirmmedicationsmismanmexamplemof mmalpractice
(d) Placingmhandsmonmamclient mwhomsaysm“domnot mtouchmme”mismanmexamplemof massault
11. Themnursemfrommthempediatricmunit mhasmbeenmtemporarilymassigned mtomthemEmergen
cymDepartment.mIt mwould mbemmostm appropriatem tomassignmthat mnursemtomthemclient mwho
*
(a) reportsmepigastricmpainmthat m“feelsmlikemindigestion”
(b) hasmbackmpainmand mampulsatingmabdominalmmass
(c) ismHIV+mreportingmvomitingmand mdiarrhea
(d) presentsmwithmlowermabdominalmpainmand mismsixmweeksmpregnant
12. Fourmclientsmrecentlymreturned mtomthemunit mfollowingminvasivemdiagnosticmtesting.m T
hemnursemshould mimmediatelymintervenem if monemof mthemclients
(a) reportsmblood mtinged msputummfollowingmambronchoscopy
(b) hasmdecreased mabdominalmgirthmfollowingmparacentesis
(c) reportsmamheadachemfollowingmamlumbarmpuncture
(d) ismobserved mflexingmand mextendingmthemlegsmtwomhoursmaftermcardiacmcatheterization
13. Themnursemismmademawaremof mthemfollowingmsituations.m Themnursemshould mfim rstmche
ckmthemclient mwho
(a) had mamtransurethralmprostatectomym(TURP)mand mismreportingmurinarymdribblingmt
womhoursmaftermthemindwellingmcathetermismremoved
(b) hasmcervicalmtractionmand mismmovingmthemlegsmbymflmexingmand mextendingmthemfeet
(c) hasmAlzheimer’smdiseasem(stagem1)mand mwasmreturned mtomthemroommaftermbeingmfou
nd mwanderingminmthemhallway
(d) hasmamhistorymof mpartialmseizuresmand mismsittingminmthembed mpickingmat mthemclothingma
nd msmackingmthemlips
14. Themnurseminmamcommunitymhealthmclinicmismtalkingmwithmthemparent mof mamchild mw
ithmCeliacmDisease.m Whichmof mthemfollowingmstatementsmwould mrequirem follow-
3
, upm bymthe
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