HESI EXIT EXAM SS5
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1. After placing a 36-week gestation newborn in an isolette and drying the
infant with several blankets, what should the nurse implement next?
a. Administer the vitamin K injection
b. Remove the wet blankets and linens from the isolette
c. Place erythromycin ophthalmic ointment in both eyes
d. Open the isolate door to assess the infants' vital signs: c. Place erythromycin
ophthalmic ointment in both eyes
2. A client in the third trimester of pregnancy complaints of frequent nasal
stuffiness and occasional nosebleeds. Her chest circumference has increased
by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm
is elevated, and she has an increased costal angle. Which intervention should
the nurse implement?
A. Ask a nurse with more experience to validate the costal angle finding
B. Ask the health care provider to evaluate the client's respiratory status
C. Examine the client for signs of tissue and anoxia, such as pallor
D. Record the respiratory finding in the client's record as normal: C. Examine
the client for signs of tissue and anoxia, such as pallor
3. A terminally ill male hospice client who is at home is showing decreased
awareness of his surroundings. His appetite is poor, and he often uses oral
intake of solids and liquids. For the past several days he has been unable to
get out of bed. Which action should the hospice nurse implement?
A. Ask family to remain nearby, but in another room
B. Encourage family to speak often with the client
C. Teach family how to assist the client to a wheelchair
D. Instruct family to offer client only soft bland foods: C. Teach family how to
assist the client to a wheelchair
4. A woman was admitted yesterday afternoon with severe abdominal pain.
Her pregnancy tests and ultrasounds were negative, so an exploratory la-
parotomy was completed during the night. When coffee ground material is
observed in the drainage from the nasal gastric tube, which intervention
should the nurse implement?
a. Verify correct placement of the nasogastric tube
b. Perform gastroccult test on the nasogastric drainage
c. Listen for evidence of diminished bowel sounds
d. Irrigate the nasogastric tube with water until clear: a. Verify correct placement
of the nasogastric tube
5. The nurse is reviewing the laboratory values for a client with acute pan-
creatitis who reports that the abdominal pain is not as severe as it was on
admission. Which laboratory test should the nurse review to evaluate the
, HESI EXIT EXAM SS5
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client's clinical recovery?
a. Lipase
b. Creatinine
c. Bilirubin
d. Glucose: a. Lipase
6. While assessing a client who had a laparotomy the previous day, the nurse
notices that 300 mL of dark red fluid has drained from the nasogastric tube in
the last hour. Which action should the nurse take first?
a. Determine the client's vital signs
b. Monitor urinary output hourly
c. Notify the surgeon immediately
d. Assess the client's level of pain: b. Determine the client's vital signs
7. The nurse is reviewing the recommended preventative care for clients with
asthma, chronic bronchitis, and emphysema. Which healthcare measure is
most important for the nurse to recommend to these clients?
a. Ensure supplemental oxygen and respiratory medications are available at
all times
b. Use nasal or cough tissues followed by hand washing at all times
c. Get annual flu and pneumococcal vaccine polyvalent vaccines
d. Avoid large crowded areas during the colder months of the year: d. Avoid
large crowded areas during the colder months of the year
8. A mother of a one-month-old infant calls the clinic to report that the back of
her infant's head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and active
b. Turn the infant on the left side braced against the crib when sleeping
c. Prop the infant in a sitting position with a cushion when not sleeping
d. Place a small pillow under the infants head while lying on the back: a.
Position the infant on the stomach occasionally when awake and active
9. A woman is brought to the labor and delivery unit after delivering a term
infant and the placenta in the hospital parking lot 10 minutes ago. Which action
should the nurse perform first?
a. Inspect the perineum for lacerations
b. Collect specimen for hemoglobin and hematocrit
c. Massage the fundus and give oxytocic agent
d. Place the infant to breast for bonding: c. Massage the fundus and give oxytocic
agent
10. A client has a new prescription for the maximum recommended dosage of
piperacillin/tazobactam for nosocomial pneumonia. The nurse should report
which laboratory finding to the health care provider before administering the
, HESI EXIT EXAM SS5
Study online at https://quizlet.com/_d6yeug
prescribed dose?
a. Elevated white blood cell count
b. Presence of gram-positive bacteria in the sputum
c. Decrease creatinine clearance
d. Elevated cholesterol and lipoproteins: b. Presence of gram-positive bacteria in
the sputum
11. A client who is admitted with diabetic ketoacidosis is demonstrating Kuss-
maul breathing and has a severe headache along with nausea. Her arterial
blood gases are: ph 7.50; paco2 30 mmhg; HCO3 24 meq/L. Which assessment
finding warrants immediate intervention by the nurse?
a. Muscle stiffness
b. Abdominal pain
c. Mental stupor
d. Fruity breath: d. Fruity breath
12. When performing postural drainage on a client with chronic obstructive
pulmonary disease, which approach should the nurse use?
a. Explain that the client may be placed in five positions
b. Instruct the client to breathe shallow and fast
c. Obtain arterial blood gases prior to the procedure
d. Perform the drainage immediately after meals: a. Explain that the client may
be placed in five positions
13. A young male client with testicular cancer has a living will that describes
his desire that no extraordinary measures be taken to save his life. The health
care provider knows the client has a good prognosis and refuses to write a
"do not resuscitate" (DNR) prescription. Which action should the nurse take?
A. Initiate an Ethics Committee review of the case
B. Place a DNR bracelet on the client's arm
C. Ensure resuscitation equipment is available
D. Ask the family to review options with the client: A. Initiate an Ethics Committee
review of the case
14. In observing a client's face, which assessment finding requires the most
immediate intervention by the nurse?
a. Cornea are jaundiced
b. Oral mucosa is cyanotic
c. Face is flushed and diaphoretic
d. Eyelids are matted and crusted: b. Oral mucosa is cyanotic
15. The nurse is assessing a client with cirrhosis and notes that the client has
a positive Babinski reflex. Which action should the nurse take in response to
the finding?
, HESI EXIT EXAM SS5
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a. Ask the client to describe recent alcohol use
b. Keep the clients feet elevated when in bed
c. Assess the clients muscle strength and tone
d. Complete a thorough neurological assessment: d. Complete a thorough neu-
rological assessment
16. Which action should the nurse take first after obtaining a urine specimen
for culture and sensitivity from an indwelling urinary catheter?
a. Ensure that the drainage bag is attached to the bed frame
b. Ensure continued sterility of the specimen container
c. Securely fasten the clamp on the drainage bag
d. Label the container with the clients identifiers: d. Label the container with the
client's identifiers.
17. The home health nurse observes an older client with unilateral weakness
place the walker in front of the chair for support while rising to a standing
position. Which action should the nurse take?
a. Hold the Walker securely to prevent slipping when the client rises
b. Applied gait belt to assist the client to rise out of the chair
c. Instruct the client to use the arms of the chair for support
d. Encourage the client to use the weaker leg with the walker when rising: c.
Instruct the client to use the arms of the chair for support.
18. A client with cancer complains of fever, chills, malaise, and headache
following administration of a colony stimulating factor. Which nursing inter-
vention is most beneficial in helping to reduce the flu like symptoms?
a. Monitor lab values for an increase in WBCs
b. Administer anti emetics before, during, and after therapy
c. Administer acetaminophen Q4H
d. Monitor vital signs Q4H for 24 hours: a. Monitor lab values for an increase in
wbcs
?
19. Which laboratory value should the nurse review prior to administering the
initial dose of a statin medication?
a. Serum electrolytes
b. Serum liver enzymes
c. Capillary blood glucose
d. Complete blood count: b. Serum liver enzymes
20. Following a lumbar puncture, the client voices several concerns. Which
concern indicates to the nurse that the client is experiencing a complication
Study online at https://quizlet.com/_d6yeug
1. After placing a 36-week gestation newborn in an isolette and drying the
infant with several blankets, what should the nurse implement next?
a. Administer the vitamin K injection
b. Remove the wet blankets and linens from the isolette
c. Place erythromycin ophthalmic ointment in both eyes
d. Open the isolate door to assess the infants' vital signs: c. Place erythromycin
ophthalmic ointment in both eyes
2. A client in the third trimester of pregnancy complaints of frequent nasal
stuffiness and occasional nosebleeds. Her chest circumference has increased
by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm
is elevated, and she has an increased costal angle. Which intervention should
the nurse implement?
A. Ask a nurse with more experience to validate the costal angle finding
B. Ask the health care provider to evaluate the client's respiratory status
C. Examine the client for signs of tissue and anoxia, such as pallor
D. Record the respiratory finding in the client's record as normal: C. Examine
the client for signs of tissue and anoxia, such as pallor
3. A terminally ill male hospice client who is at home is showing decreased
awareness of his surroundings. His appetite is poor, and he often uses oral
intake of solids and liquids. For the past several days he has been unable to
get out of bed. Which action should the hospice nurse implement?
A. Ask family to remain nearby, but in another room
B. Encourage family to speak often with the client
C. Teach family how to assist the client to a wheelchair
D. Instruct family to offer client only soft bland foods: C. Teach family how to
assist the client to a wheelchair
4. A woman was admitted yesterday afternoon with severe abdominal pain.
Her pregnancy tests and ultrasounds were negative, so an exploratory la-
parotomy was completed during the night. When coffee ground material is
observed in the drainage from the nasal gastric tube, which intervention
should the nurse implement?
a. Verify correct placement of the nasogastric tube
b. Perform gastroccult test on the nasogastric drainage
c. Listen for evidence of diminished bowel sounds
d. Irrigate the nasogastric tube with water until clear: a. Verify correct placement
of the nasogastric tube
5. The nurse is reviewing the laboratory values for a client with acute pan-
creatitis who reports that the abdominal pain is not as severe as it was on
admission. Which laboratory test should the nurse review to evaluate the
, HESI EXIT EXAM SS5
Study online at https://quizlet.com/_d6yeug
client's clinical recovery?
a. Lipase
b. Creatinine
c. Bilirubin
d. Glucose: a. Lipase
6. While assessing a client who had a laparotomy the previous day, the nurse
notices that 300 mL of dark red fluid has drained from the nasogastric tube in
the last hour. Which action should the nurse take first?
a. Determine the client's vital signs
b. Monitor urinary output hourly
c. Notify the surgeon immediately
d. Assess the client's level of pain: b. Determine the client's vital signs
7. The nurse is reviewing the recommended preventative care for clients with
asthma, chronic bronchitis, and emphysema. Which healthcare measure is
most important for the nurse to recommend to these clients?
a. Ensure supplemental oxygen and respiratory medications are available at
all times
b. Use nasal or cough tissues followed by hand washing at all times
c. Get annual flu and pneumococcal vaccine polyvalent vaccines
d. Avoid large crowded areas during the colder months of the year: d. Avoid
large crowded areas during the colder months of the year
8. A mother of a one-month-old infant calls the clinic to report that the back of
her infant's head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and active
b. Turn the infant on the left side braced against the crib when sleeping
c. Prop the infant in a sitting position with a cushion when not sleeping
d. Place a small pillow under the infants head while lying on the back: a.
Position the infant on the stomach occasionally when awake and active
9. A woman is brought to the labor and delivery unit after delivering a term
infant and the placenta in the hospital parking lot 10 minutes ago. Which action
should the nurse perform first?
a. Inspect the perineum for lacerations
b. Collect specimen for hemoglobin and hematocrit
c. Massage the fundus and give oxytocic agent
d. Place the infant to breast for bonding: c. Massage the fundus and give oxytocic
agent
10. A client has a new prescription for the maximum recommended dosage of
piperacillin/tazobactam for nosocomial pneumonia. The nurse should report
which laboratory finding to the health care provider before administering the
, HESI EXIT EXAM SS5
Study online at https://quizlet.com/_d6yeug
prescribed dose?
a. Elevated white blood cell count
b. Presence of gram-positive bacteria in the sputum
c. Decrease creatinine clearance
d. Elevated cholesterol and lipoproteins: b. Presence of gram-positive bacteria in
the sputum
11. A client who is admitted with diabetic ketoacidosis is demonstrating Kuss-
maul breathing and has a severe headache along with nausea. Her arterial
blood gases are: ph 7.50; paco2 30 mmhg; HCO3 24 meq/L. Which assessment
finding warrants immediate intervention by the nurse?
a. Muscle stiffness
b. Abdominal pain
c. Mental stupor
d. Fruity breath: d. Fruity breath
12. When performing postural drainage on a client with chronic obstructive
pulmonary disease, which approach should the nurse use?
a. Explain that the client may be placed in five positions
b. Instruct the client to breathe shallow and fast
c. Obtain arterial blood gases prior to the procedure
d. Perform the drainage immediately after meals: a. Explain that the client may
be placed in five positions
13. A young male client with testicular cancer has a living will that describes
his desire that no extraordinary measures be taken to save his life. The health
care provider knows the client has a good prognosis and refuses to write a
"do not resuscitate" (DNR) prescription. Which action should the nurse take?
A. Initiate an Ethics Committee review of the case
B. Place a DNR bracelet on the client's arm
C. Ensure resuscitation equipment is available
D. Ask the family to review options with the client: A. Initiate an Ethics Committee
review of the case
14. In observing a client's face, which assessment finding requires the most
immediate intervention by the nurse?
a. Cornea are jaundiced
b. Oral mucosa is cyanotic
c. Face is flushed and diaphoretic
d. Eyelids are matted and crusted: b. Oral mucosa is cyanotic
15. The nurse is assessing a client with cirrhosis and notes that the client has
a positive Babinski reflex. Which action should the nurse take in response to
the finding?
, HESI EXIT EXAM SS5
Study online at https://quizlet.com/_d6yeug
a. Ask the client to describe recent alcohol use
b. Keep the clients feet elevated when in bed
c. Assess the clients muscle strength and tone
d. Complete a thorough neurological assessment: d. Complete a thorough neu-
rological assessment
16. Which action should the nurse take first after obtaining a urine specimen
for culture and sensitivity from an indwelling urinary catheter?
a. Ensure that the drainage bag is attached to the bed frame
b. Ensure continued sterility of the specimen container
c. Securely fasten the clamp on the drainage bag
d. Label the container with the clients identifiers: d. Label the container with the
client's identifiers.
17. The home health nurse observes an older client with unilateral weakness
place the walker in front of the chair for support while rising to a standing
position. Which action should the nurse take?
a. Hold the Walker securely to prevent slipping when the client rises
b. Applied gait belt to assist the client to rise out of the chair
c. Instruct the client to use the arms of the chair for support
d. Encourage the client to use the weaker leg with the walker when rising: c.
Instruct the client to use the arms of the chair for support.
18. A client with cancer complains of fever, chills, malaise, and headache
following administration of a colony stimulating factor. Which nursing inter-
vention is most beneficial in helping to reduce the flu like symptoms?
a. Monitor lab values for an increase in WBCs
b. Administer anti emetics before, during, and after therapy
c. Administer acetaminophen Q4H
d. Monitor vital signs Q4H for 24 hours: a. Monitor lab values for an increase in
wbcs
?
19. Which laboratory value should the nurse review prior to administering the
initial dose of a statin medication?
a. Serum electrolytes
b. Serum liver enzymes
c. Capillary blood glucose
d. Complete blood count: b. Serum liver enzymes
20. Following a lumbar puncture, the client voices several concerns. Which
concern indicates to the nurse that the client is experiencing a complication
