366 EXIT HESI: EXAM, 2025/2026 WITH
CORRECT/ACCURATE ANSWERS
A young adult female is brought to the emergency room by family
members who report that she ingested a large quantity of
acetaminophen (Tylenol). The nurse should prepare for which
treatment to be implemented?
1. IV administration of Narcan.
2. Syrup of ipecac per nasogastric tube.
3. Acetylcysteine (Mucomyst) 140 mg/kg.
4. Gastric lavage with normal saline. - CORRECT ANSWERS- 3.
Acetylcysteine (Mucomyst) 140 mg/kg
Mucomyst is the antidote for acute acetaminophen (Tylenol)
poisoning and is the treatment of choice for an overdose.
A newly admitted client complains of pain rating a 7 on a scale of
0 to 10. The client has not been sleeping well lately and is
experiencing labored breathing. List the client's problems in order
of priority for the nurse. (Rank in the priority order from highest to
lowest.)
1.
Airway and breathing.
2.
,Pain management.
3.
Definitive therapy.
4.
Sleep and rest. - CORRECT ANSWERS- Correct Answer:
1.Airway and breathing. 2.Pain management. 3.Sleep and rest.
4.Definitive therapy.
Rationale
First-level problems are immediate priorities (airway, breathing,
and circulation). In this scenario, airway and breathing are the
first priority, followed by pain management, Maslow's hierarchy of
basic needs for rest and sleep, and then definitive drug therapies.
While auscultating the lungs of a client who is being mechanically
ventilated, the nurse hears coarse, snoring sounds over the upper
anterior chest with clear sounds over the other lung fields. Based
on these assessment findings, which action should the nurse
take?
1. Notify respiratory therapy immediately for a PRN
bronchodilator treatment.
2. Obtain a prescription to increase the tidal volume setting on
the ventilator.
3. Stop mechanical ventilation and re-assess the client's lung
sounds bilaterally.
,4. Suction the client's endotracheal tube and auscultate following
suctioning. - CORRECT ANSWERS- 4. Suction the client's
endotracheal tube and auscultate following suctioning.
Suctioning the ET tube clears secretions and will usually eliminate
the coarse snorous sounds. Respiratory therapy usually provides
treatments when airways are edematous, not for secretions.
Changing the tidal volume will not clear the airways. Clients on a
ventilator will have sounds of the ventilator working, however the
ventilator should not be stopped for auscultation of breath
sounds.
Which type of management style is a case management model
for nursing care delivery?
1. Patient focused and primary nursing.
2. Clinically oriented and business oriented.
3. Centralized and decentralized systems models.
4. Clinical pathways and patient classifications. - CORRECT
ANSWERS- 1. Patient focused and primary nursing.
A client classification or acuity system is used in many acute care
hospitals to estimate the intensity of nursing care required to
meet patient needs. Case management is patient focused and
provides primary nursing. Clinically- and business-oriented is a
business model of organizational decision making. Centralized
and decentralized systems models are management strategies or
models of organizational decision making, such as shared
governance which is a decentralized model. Clinical pathways are
interdisciplinary plans of care that outline the optimal sequencing
, and timing of interventions for clients with a particular diagnosis,
procedure, or symptoms.
The nurse is informed that a client is returning to the unit from
the post-anesthesia care unit following abdominal surgery. Which
task is best to delegate to the unlicensed assistive personnel
(UAP)?
1. Assess breathing pattern after transport is completed.
2. Notify the family that the client is returning from surgery.
3. Report to the charge nurse the appearance of the dressing.
4. Assist the transport team with transferring the client to the
bed. - CORRECT ANSWERS- 4. Assist the transport team with
transferring the client to the bed.
The UAP can be assigned to assist with transferring the client
from the gurney to the bed since repositioning following
abdominal surgery is not a high-risk intervention and does not
require nursing judgment. Assessing breath sounds requires
judgment and should be performed by a licensed person.
Notifying family should be done by the nurse who may provide
additional information if requested. The nurse should directly
observe the dressing and should not rely on the UAP's
assessment of the dressing's appearance.
A client with chronic kidney disease (CKD) and severe anemia
refuses blood transfusions. The healthcare provider prescribes
epoetin alfa. Which action should the nurse explain to the client
about the medication's therapeutic response?
CORRECT/ACCURATE ANSWERS
A young adult female is brought to the emergency room by family
members who report that she ingested a large quantity of
acetaminophen (Tylenol). The nurse should prepare for which
treatment to be implemented?
1. IV administration of Narcan.
2. Syrup of ipecac per nasogastric tube.
3. Acetylcysteine (Mucomyst) 140 mg/kg.
4. Gastric lavage with normal saline. - CORRECT ANSWERS- 3.
Acetylcysteine (Mucomyst) 140 mg/kg
Mucomyst is the antidote for acute acetaminophen (Tylenol)
poisoning and is the treatment of choice for an overdose.
A newly admitted client complains of pain rating a 7 on a scale of
0 to 10. The client has not been sleeping well lately and is
experiencing labored breathing. List the client's problems in order
of priority for the nurse. (Rank in the priority order from highest to
lowest.)
1.
Airway and breathing.
2.
,Pain management.
3.
Definitive therapy.
4.
Sleep and rest. - CORRECT ANSWERS- Correct Answer:
1.Airway and breathing. 2.Pain management. 3.Sleep and rest.
4.Definitive therapy.
Rationale
First-level problems are immediate priorities (airway, breathing,
and circulation). In this scenario, airway and breathing are the
first priority, followed by pain management, Maslow's hierarchy of
basic needs for rest and sleep, and then definitive drug therapies.
While auscultating the lungs of a client who is being mechanically
ventilated, the nurse hears coarse, snoring sounds over the upper
anterior chest with clear sounds over the other lung fields. Based
on these assessment findings, which action should the nurse
take?
1. Notify respiratory therapy immediately for a PRN
bronchodilator treatment.
2. Obtain a prescription to increase the tidal volume setting on
the ventilator.
3. Stop mechanical ventilation and re-assess the client's lung
sounds bilaterally.
,4. Suction the client's endotracheal tube and auscultate following
suctioning. - CORRECT ANSWERS- 4. Suction the client's
endotracheal tube and auscultate following suctioning.
Suctioning the ET tube clears secretions and will usually eliminate
the coarse snorous sounds. Respiratory therapy usually provides
treatments when airways are edematous, not for secretions.
Changing the tidal volume will not clear the airways. Clients on a
ventilator will have sounds of the ventilator working, however the
ventilator should not be stopped for auscultation of breath
sounds.
Which type of management style is a case management model
for nursing care delivery?
1. Patient focused and primary nursing.
2. Clinically oriented and business oriented.
3. Centralized and decentralized systems models.
4. Clinical pathways and patient classifications. - CORRECT
ANSWERS- 1. Patient focused and primary nursing.
A client classification or acuity system is used in many acute care
hospitals to estimate the intensity of nursing care required to
meet patient needs. Case management is patient focused and
provides primary nursing. Clinically- and business-oriented is a
business model of organizational decision making. Centralized
and decentralized systems models are management strategies or
models of organizational decision making, such as shared
governance which is a decentralized model. Clinical pathways are
interdisciplinary plans of care that outline the optimal sequencing
, and timing of interventions for clients with a particular diagnosis,
procedure, or symptoms.
The nurse is informed that a client is returning to the unit from
the post-anesthesia care unit following abdominal surgery. Which
task is best to delegate to the unlicensed assistive personnel
(UAP)?
1. Assess breathing pattern after transport is completed.
2. Notify the family that the client is returning from surgery.
3. Report to the charge nurse the appearance of the dressing.
4. Assist the transport team with transferring the client to the
bed. - CORRECT ANSWERS- 4. Assist the transport team with
transferring the client to the bed.
The UAP can be assigned to assist with transferring the client
from the gurney to the bed since repositioning following
abdominal surgery is not a high-risk intervention and does not
require nursing judgment. Assessing breath sounds requires
judgment and should be performed by a licensed person.
Notifying family should be done by the nurse who may provide
additional information if requested. The nurse should directly
observe the dressing and should not rely on the UAP's
assessment of the dressing's appearance.
A client with chronic kidney disease (CKD) and severe anemia
refuses blood transfusions. The healthcare provider prescribes
epoetin alfa. Which action should the nurse explain to the client
about the medication's therapeutic response?
