NCLEX/EXIT HESI Critical Thinking
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1. Which client would benefit from the application of warm moist heat?: a client
with low back pain
Direct application of warm moist heat would benefit a client with low back pain
because the heat relaxes muscle spasms. Heat should not be applied to a client who
has appendicitis because it can lead to rupture of the appendix and peritonitis. Ice
is applied to recently sprained joints to help decrease edema. Applying heat to the
area of a suspected malignancy can increase blood flow to the tumor and promote
nourishment of the cancer cells.
2. A nurse is administering vitamin K to a neonate following birth. The medica-
tion comes in a concentration of 2 mg/ml, and the ordered dose is 0.5 mg to
be given subcutaneously. How many milliliters would the nurse administer?
Record your answer using two decimal places.: 0.25
Use the following formula to calculate drug dosages:Dose on hand/Quantity on hand
= Dose desired/XPlug in the values and the equation is as follows:2 mg/ml = 0.5
mg/XX = 0.25 ml.
3. A child is to receive IV fluids at a rate of 95 mL/h. The tubing for the infusion
delivers 10 drops/mL. At which rate should the nurse infuse the solution?: 16
drops/min
To determine the number of drops per minute, multiply 95 ml/hour by 10 drops/mL
(drop factor). This equals 950 mL/h. Dividing 950 mL/h by 60 min/h yields 15.8
drops/min. Therefore, 16 drops/min should be infused.
4. A 5-year-old child is brought to the emergency department after injuries sus-
tained in a motor vehicle accident. The child is diagnosed with a cervical spinal
cord injury. Which assessment data would the nurse consider as most signif-
icant when assessing for signs of cervical spinal cord swelling?: changes in
respiration
Impaired diaphragm function is common with cervical cord injuries in children and is
potentially life threatening. It interferes with the ability to breathe, causing changes
in respiration.
5. The healthcare provider prescribes meperidine hydrochloride 1.5 mg/kg
intramuscularly to a school-age client. The pharmacy supplies meperidine
hydrochloride injection as 50 mg/mL. The client weighs 25 kg. How many
milliliters will the nurse administer? Record your answer using two decimal
places.: 0.75
, NCLEX/EXIT HESI Critical Thinking
Study online at https://quizlet.com/_efj7en
1.5 mg/kg × 25 kg = 37.5 mg per dose
37.5 mg / 50 mg x 1ml = 0.75 ml for injection
6. A client with a bleeding ulcer is vomiting bright red blood. The nurse should
assess the client for which indicator of early shock?: heart rate above 100
beats/minute
In early shock, the body attempts to meet its perfusion needs through tachycardia,
vasoconstriction, and fluid conservation.The skin becomes cool and clammy.Urine
output in early shock may be normal or slightly decreased.The client may experience
increased restlessness and anxiety from hypoxia, but loss of consciousness is a late
sign of shock.
7. A client reports pain in the right heel and is requesting medication. The
nurse assesses the client and administers an analgesic. The client expe-
riences no pain relief and states that the heel pain is worse. What is an
appropriate intervention by the nurse?: Call the physician to report the finding.
The best response would be to notify the physician. The nurse cannot repeat the
dose of analgesic without an order. Massaging the ankle and applying moist heat
would be inappropriate for a number of reasons. The client could be developing a
deep vein thrombosis, which may dislodge an embolus. Unrelieved pain indicates
that an adverse event is developing, and the physician should be made aware of the
situation.
8. A client has suffered a deep partial-thickness burn to the right arm from
a high-voltage source of energy that was not turned off while working on it.
What is the priority nursing intervention in the acute phase of care?: A cardiac
monitor should be used for at least 24 hours to anticipate the potential for cardiac
dysrhythmias.
A client with electrical burns based on energy and potential damage to the heart
needs cardiac monitoring. Dextrose is not useful for fluid volume expansion and
infection would occur much later. Urine output needs hourly monitoring based on
myoglobin release.
9. During the nurse's assessment, the newborn wakes and is in a quiet-alert
state. The nurse counts the apical pulse to be 157 beats per minute. Which is
the most appropriate nursing action?: Document this finding as on the high end
of the normal range and plan to reassess.
Heart rates can be as fast as 180 bpm, but the normal range for a newborn heart rate
is 110-160 bpm. Thus, the newborn's heart rate of 157 bpm is on the high end of the
, NCLEX/EXIT HESI Critical Thinking
Study online at https://quizlet.com/_efj7en
normal range, but still within the normal range. It would be appropriate to reassess
the client's heart rate because newborn heart rates can fluctuate depending on
the state of consciousness/wakefulness, hunger, temperature, and especially if the
newborn is moving or startled. It would be inappropriate to call the pediatrician or to
notify the charge nurse at this time because the value is currently within the normal
range.
10. When developing the collaborative plan of care with the health care
provider (HCP) for a multigravid client at 10 weeks' gestation with a history
of cardiac disease who was being treated with digitalis therapy before this
pregnancy, the nurse should instruct the client about which modifications
regarding the client's drug therapy regimen?: need for an increased dosage
Clients on cardiac medications may need dosage increases as their blood volume
increases. Drug level monitoring may be needed after dose changes or if the client
presents with toxicity, but weekly monitoring is unnecessary. The medication would
be switched only if digitalis toxicity occurs. A diuretic is added only if congestive heart
failure is not controlled by sodium and activity restrictions.
11. A full-term client is admitted for induction of labor. When admitted, her
cervix is effaced 25% but has not dilated. The initial goal is cervical ripening
prior to labor induction. Which drug will prepare her cervix for induction?: -
dinoprostone
Cervical ripening, or creating a cervix that is soft, anterior, and dilated to 2 to
3 cm, must occur before the cervix can efface and dilate with oxytocin. Drugs
to accomplish this goal include dinoprostone, misoprostol, and prostaglandin E2.
Nalbuphine is a narcotic analgesic used in early labor and has no influence on the
cervix. Betamethasone is a corticosteroid given to mature fetal lungs.
12. When assessing a client with asthma, which findings would most likely
indicate the presence of a respiratory infection?: cough productive of yellow
sputum
A cough productive of yellow sputum is the most likely indicator of a respiratory
infection. The other signs and symptoms—wheezing, chest tightness, and increased
respiratory rate—are all findings associated with an asthma attack and do not
necessarily mean an infection is present.
13. A client's blood glucose level is 45 mg/dl (2.5 mmol/L). The nurse should
be alert for which signs and symptoms?: coma, anxiety, confusion, headache,
and cool, moist skin
, NCLEX/EXIT HESI Critical Thinking
Study online at https://quizlet.com/_efj7en
Signs and symptoms of hypoglycemia [indicated by a blood glucose level of 45
mg/dl (2.5 mmol/L)] include anxiety, restlessness, headache, irritability, confusion,
diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul's respirations, dry
skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive
thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus.
Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms
of diabetes mellitus.
14. A client admitted with multiple traumatic injuries receives massive flu-
id resuscitation. Later, the physician suspects that the client has aspirated
stomach contents. The nurse knows to monitor closely for complications that
include which of the following?: acute respiratory distress syndrome (ARDS)
A client who receives massive fluid resuscitation or blood transfusions or who
aspirates stomach contents is at highest risk for ARDS, which is associated with
catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drown-
ing, and smoke inhalation. ARDS refers to a group of chronic diseases, including
bronchial asthma, characterized by recurring airflow obstruction in the lungs. Al-
though renal failure may occur in a client with multiple trauma (depending on the
organs involved), this client's history points to an assault on the respiratory system
secondary to aspiration of stomach contents and massive fluid resuscitation.
15. Which assessment should be the priority for an infant who has had surgery
to correct an intussusception and is now at risk for development of a paralytic
ileus postoperatively?: auscultation of bowel sounds
Development of a paralytic ileus postoperatively is a functional obstruction of the
bowel. Bowel sounds initially may be hyperactive, but then they diminish and cease.
Measurement of urine specific gravity provides information about fluid and elec-
trolyte status. The first stool and the amount of gastric output provide information
about the return of gastric function.
16. The nurse is assessing a client recovering from anesthesia. Which finding
is an early indicator of hypoxemia?: restlessness
One of the earliest signs of hypoxia is restlessness and agitation. Decreased level
of consciousness and somnolence are later signs of hypoxia. Chills can be related
to the anesthetic agent used but are not indicative of hypoxia. Urgency is not related
to hypoxia.
17. A client is recovering from surgical repair of a dissecting aortic aneurysm.
Which assessment findings indicate possible bleeding or recurring dissec-
tion?: blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
Study online at https://quizlet.com/_efj7en
1. Which client would benefit from the application of warm moist heat?: a client
with low back pain
Direct application of warm moist heat would benefit a client with low back pain
because the heat relaxes muscle spasms. Heat should not be applied to a client who
has appendicitis because it can lead to rupture of the appendix and peritonitis. Ice
is applied to recently sprained joints to help decrease edema. Applying heat to the
area of a suspected malignancy can increase blood flow to the tumor and promote
nourishment of the cancer cells.
2. A nurse is administering vitamin K to a neonate following birth. The medica-
tion comes in a concentration of 2 mg/ml, and the ordered dose is 0.5 mg to
be given subcutaneously. How many milliliters would the nurse administer?
Record your answer using two decimal places.: 0.25
Use the following formula to calculate drug dosages:Dose on hand/Quantity on hand
= Dose desired/XPlug in the values and the equation is as follows:2 mg/ml = 0.5
mg/XX = 0.25 ml.
3. A child is to receive IV fluids at a rate of 95 mL/h. The tubing for the infusion
delivers 10 drops/mL. At which rate should the nurse infuse the solution?: 16
drops/min
To determine the number of drops per minute, multiply 95 ml/hour by 10 drops/mL
(drop factor). This equals 950 mL/h. Dividing 950 mL/h by 60 min/h yields 15.8
drops/min. Therefore, 16 drops/min should be infused.
4. A 5-year-old child is brought to the emergency department after injuries sus-
tained in a motor vehicle accident. The child is diagnosed with a cervical spinal
cord injury. Which assessment data would the nurse consider as most signif-
icant when assessing for signs of cervical spinal cord swelling?: changes in
respiration
Impaired diaphragm function is common with cervical cord injuries in children and is
potentially life threatening. It interferes with the ability to breathe, causing changes
in respiration.
5. The healthcare provider prescribes meperidine hydrochloride 1.5 mg/kg
intramuscularly to a school-age client. The pharmacy supplies meperidine
hydrochloride injection as 50 mg/mL. The client weighs 25 kg. How many
milliliters will the nurse administer? Record your answer using two decimal
places.: 0.75
, NCLEX/EXIT HESI Critical Thinking
Study online at https://quizlet.com/_efj7en
1.5 mg/kg × 25 kg = 37.5 mg per dose
37.5 mg / 50 mg x 1ml = 0.75 ml for injection
6. A client with a bleeding ulcer is vomiting bright red blood. The nurse should
assess the client for which indicator of early shock?: heart rate above 100
beats/minute
In early shock, the body attempts to meet its perfusion needs through tachycardia,
vasoconstriction, and fluid conservation.The skin becomes cool and clammy.Urine
output in early shock may be normal or slightly decreased.The client may experience
increased restlessness and anxiety from hypoxia, but loss of consciousness is a late
sign of shock.
7. A client reports pain in the right heel and is requesting medication. The
nurse assesses the client and administers an analgesic. The client expe-
riences no pain relief and states that the heel pain is worse. What is an
appropriate intervention by the nurse?: Call the physician to report the finding.
The best response would be to notify the physician. The nurse cannot repeat the
dose of analgesic without an order. Massaging the ankle and applying moist heat
would be inappropriate for a number of reasons. The client could be developing a
deep vein thrombosis, which may dislodge an embolus. Unrelieved pain indicates
that an adverse event is developing, and the physician should be made aware of the
situation.
8. A client has suffered a deep partial-thickness burn to the right arm from
a high-voltage source of energy that was not turned off while working on it.
What is the priority nursing intervention in the acute phase of care?: A cardiac
monitor should be used for at least 24 hours to anticipate the potential for cardiac
dysrhythmias.
A client with electrical burns based on energy and potential damage to the heart
needs cardiac monitoring. Dextrose is not useful for fluid volume expansion and
infection would occur much later. Urine output needs hourly monitoring based on
myoglobin release.
9. During the nurse's assessment, the newborn wakes and is in a quiet-alert
state. The nurse counts the apical pulse to be 157 beats per minute. Which is
the most appropriate nursing action?: Document this finding as on the high end
of the normal range and plan to reassess.
Heart rates can be as fast as 180 bpm, but the normal range for a newborn heart rate
is 110-160 bpm. Thus, the newborn's heart rate of 157 bpm is on the high end of the
, NCLEX/EXIT HESI Critical Thinking
Study online at https://quizlet.com/_efj7en
normal range, but still within the normal range. It would be appropriate to reassess
the client's heart rate because newborn heart rates can fluctuate depending on
the state of consciousness/wakefulness, hunger, temperature, and especially if the
newborn is moving or startled. It would be inappropriate to call the pediatrician or to
notify the charge nurse at this time because the value is currently within the normal
range.
10. When developing the collaborative plan of care with the health care
provider (HCP) for a multigravid client at 10 weeks' gestation with a history
of cardiac disease who was being treated with digitalis therapy before this
pregnancy, the nurse should instruct the client about which modifications
regarding the client's drug therapy regimen?: need for an increased dosage
Clients on cardiac medications may need dosage increases as their blood volume
increases. Drug level monitoring may be needed after dose changes or if the client
presents with toxicity, but weekly monitoring is unnecessary. The medication would
be switched only if digitalis toxicity occurs. A diuretic is added only if congestive heart
failure is not controlled by sodium and activity restrictions.
11. A full-term client is admitted for induction of labor. When admitted, her
cervix is effaced 25% but has not dilated. The initial goal is cervical ripening
prior to labor induction. Which drug will prepare her cervix for induction?: -
dinoprostone
Cervical ripening, or creating a cervix that is soft, anterior, and dilated to 2 to
3 cm, must occur before the cervix can efface and dilate with oxytocin. Drugs
to accomplish this goal include dinoprostone, misoprostol, and prostaglandin E2.
Nalbuphine is a narcotic analgesic used in early labor and has no influence on the
cervix. Betamethasone is a corticosteroid given to mature fetal lungs.
12. When assessing a client with asthma, which findings would most likely
indicate the presence of a respiratory infection?: cough productive of yellow
sputum
A cough productive of yellow sputum is the most likely indicator of a respiratory
infection. The other signs and symptoms—wheezing, chest tightness, and increased
respiratory rate—are all findings associated with an asthma attack and do not
necessarily mean an infection is present.
13. A client's blood glucose level is 45 mg/dl (2.5 mmol/L). The nurse should
be alert for which signs and symptoms?: coma, anxiety, confusion, headache,
and cool, moist skin
, NCLEX/EXIT HESI Critical Thinking
Study online at https://quizlet.com/_efj7en
Signs and symptoms of hypoglycemia [indicated by a blood glucose level of 45
mg/dl (2.5 mmol/L)] include anxiety, restlessness, headache, irritability, confusion,
diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul's respirations, dry
skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive
thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus.
Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms
of diabetes mellitus.
14. A client admitted with multiple traumatic injuries receives massive flu-
id resuscitation. Later, the physician suspects that the client has aspirated
stomach contents. The nurse knows to monitor closely for complications that
include which of the following?: acute respiratory distress syndrome (ARDS)
A client who receives massive fluid resuscitation or blood transfusions or who
aspirates stomach contents is at highest risk for ARDS, which is associated with
catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drown-
ing, and smoke inhalation. ARDS refers to a group of chronic diseases, including
bronchial asthma, characterized by recurring airflow obstruction in the lungs. Al-
though renal failure may occur in a client with multiple trauma (depending on the
organs involved), this client's history points to an assault on the respiratory system
secondary to aspiration of stomach contents and massive fluid resuscitation.
15. Which assessment should be the priority for an infant who has had surgery
to correct an intussusception and is now at risk for development of a paralytic
ileus postoperatively?: auscultation of bowel sounds
Development of a paralytic ileus postoperatively is a functional obstruction of the
bowel. Bowel sounds initially may be hyperactive, but then they diminish and cease.
Measurement of urine specific gravity provides information about fluid and elec-
trolyte status. The first stool and the amount of gastric output provide information
about the return of gastric function.
16. The nurse is assessing a client recovering from anesthesia. Which finding
is an early indicator of hypoxemia?: restlessness
One of the earliest signs of hypoxia is restlessness and agitation. Decreased level
of consciousness and somnolence are later signs of hypoxia. Chills can be related
to the anesthetic agent used but are not indicative of hypoxia. Urgency is not related
to hypoxia.
17. A client is recovering from surgical repair of a dissecting aortic aneurysm.
Which assessment findings indicate possible bleeding or recurring dissec-
tion?: blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
