900 Exit Hesi Questions and answers
2025|success guaranteed exam
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 - answ✔✔B. Place a mask on
the client's face.
An older client is admitted for repair of a broken hip. To reduce the risk
for infection in the postoperative period, which nursing care
interventions should the nurse include in the client's plan of care?
(Select all that apply)
A. Teach client to use incentive spirometer q2 hours while awake.
B. Remove urinary catheter as soon as possible and encourage voiding.
C. Maintain sequential compression devices while in bed.
D. Administer low molecular weight heparin as prescribed
,E. Assess pain level and medicate PRN as prescribed. - answ✔✔A.
Teach client to use incentive spirometer q2 hours while awake.
B. Remove urinary catheter as soon as possible and encourage voiding.
A client is scheduled to receive an IW dose of ondansetron (Zofran)
eight hours after receiving chemotherapy. The client has saline lock and
is sleeping quietly without any restlessness. The nurse caring for the
client is not certified in chemotherapy administration. What action
should the nurse take?
Ask a chemotherapy-certified nurse to administer the Zofran
Administer the ondasentron (Zofran) after flushing the saline lock with
saline
Hold the scheduled dose of Zofran until the client awakens
Awaken the client to assess the need for administration of the Zofran. -
answ✔✔Administer the ondasentron (Zofran) after flushing the saline
lock with saline
Following discharge teaching, a male client with duodenal ulcer tells the
nurse the he will drink plenty of dairy products, such as milk, to help
coat and protect his ulcer. What is the best follow-up action by the
nurse? - answ✔✔Review with the client the need to avoid foods that
are rich in milk and cream
A male client with hypertension, who received new antihypertensive
prescriptions at his last visit returns to the clinic two weeks later to
evaluate his blood pressure (BP). His BP is 158/106 and he admits that
,he has not been taking the prescribed medication because the drugs
make him "feel bad". In explaining the need for hypertension control,
the nurse should stress that an elevated BP places the client at risk for
which pathophysiological condition? - answ✔✔Stroke secondary to
hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning
a newly admitted client who has a seizure disorder. The client is supine
and the UAP is placing soft pillows along the side rails. What action
should the nurse implement? - answ✔✔Instruct the UAP to obtain soft
blankets to secure to the side rails instead of pillows.
An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for the past 12 days. Which assessment finding
requires immediate follow-up? - answ✔✔Describes life without
purpose
A 60-year-old female client with a positive family history of ovarian
cancer has developed an abdominal mass and is being evaluated for
possible ovarian cancer. Her Papanicolau (Pap) smear results are
negative. What information should the nurse include in the client's
teaching plan? - answ✔✔Further evaluation involving surgery may be
needed
A client who recently underwear a tracheostomy is being prepared for
discharge to home. Which instructions is most important for the nurse
, to include in the discharge plan? - answ✔✔Teach tracheal suctioning
techniques
In assessing an adult client with a partial rebreather mask, the nurse
notes that the oxygen reservoir bag does not deflate completely during
inspiration and the client's respiratory rate is 14 breaths / minute. What
action should the nurse implement? - answ✔✔Document the
assessment data
Rational: reservoir bag should not deflate completely during inspiration
and the client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring
system alarms. Which client alarm should the nurse investigate firs? -
answ✔✔Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes
slip and fall. What action should the nurse take first? - answ✔✔Check
the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean
section (C-Section), the client tells the nurse that she drank a cup a
coffee at 0400 because she wanted to avoid getting a headache. Which
action should the nurse take first? - answ✔✔Inform the anesthesia
care provider
2025|success guaranteed exam
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 - answ✔✔B. Place a mask on
the client's face.
An older client is admitted for repair of a broken hip. To reduce the risk
for infection in the postoperative period, which nursing care
interventions should the nurse include in the client's plan of care?
(Select all that apply)
A. Teach client to use incentive spirometer q2 hours while awake.
B. Remove urinary catheter as soon as possible and encourage voiding.
C. Maintain sequential compression devices while in bed.
D. Administer low molecular weight heparin as prescribed
,E. Assess pain level and medicate PRN as prescribed. - answ✔✔A.
Teach client to use incentive spirometer q2 hours while awake.
B. Remove urinary catheter as soon as possible and encourage voiding.
A client is scheduled to receive an IW dose of ondansetron (Zofran)
eight hours after receiving chemotherapy. The client has saline lock and
is sleeping quietly without any restlessness. The nurse caring for the
client is not certified in chemotherapy administration. What action
should the nurse take?
Ask a chemotherapy-certified nurse to administer the Zofran
Administer the ondasentron (Zofran) after flushing the saline lock with
saline
Hold the scheduled dose of Zofran until the client awakens
Awaken the client to assess the need for administration of the Zofran. -
answ✔✔Administer the ondasentron (Zofran) after flushing the saline
lock with saline
Following discharge teaching, a male client with duodenal ulcer tells the
nurse the he will drink plenty of dairy products, such as milk, to help
coat and protect his ulcer. What is the best follow-up action by the
nurse? - answ✔✔Review with the client the need to avoid foods that
are rich in milk and cream
A male client with hypertension, who received new antihypertensive
prescriptions at his last visit returns to the clinic two weeks later to
evaluate his blood pressure (BP). His BP is 158/106 and he admits that
,he has not been taking the prescribed medication because the drugs
make him "feel bad". In explaining the need for hypertension control,
the nurse should stress that an elevated BP places the client at risk for
which pathophysiological condition? - answ✔✔Stroke secondary to
hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning
a newly admitted client who has a seizure disorder. The client is supine
and the UAP is placing soft pillows along the side rails. What action
should the nurse implement? - answ✔✔Instruct the UAP to obtain soft
blankets to secure to the side rails instead of pillows.
An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for the past 12 days. Which assessment finding
requires immediate follow-up? - answ✔✔Describes life without
purpose
A 60-year-old female client with a positive family history of ovarian
cancer has developed an abdominal mass and is being evaluated for
possible ovarian cancer. Her Papanicolau (Pap) smear results are
negative. What information should the nurse include in the client's
teaching plan? - answ✔✔Further evaluation involving surgery may be
needed
A client who recently underwear a tracheostomy is being prepared for
discharge to home. Which instructions is most important for the nurse
, to include in the discharge plan? - answ✔✔Teach tracheal suctioning
techniques
In assessing an adult client with a partial rebreather mask, the nurse
notes that the oxygen reservoir bag does not deflate completely during
inspiration and the client's respiratory rate is 14 breaths / minute. What
action should the nurse implement? - answ✔✔Document the
assessment data
Rational: reservoir bag should not deflate completely during inspiration
and the client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring
system alarms. Which client alarm should the nurse investigate firs? -
answ✔✔Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes
slip and fall. What action should the nurse take first? - answ✔✔Check
the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean
section (C-Section), the client tells the nurse that she drank a cup a
coffee at 0400 because she wanted to avoid getting a headache. Which
action should the nurse take first? - answ✔✔Inform the anesthesia
care provider
