Hesi Exit V3 Exam (Actual Exam) Questions and Verified Answers
Which assessment should the home health nurse include during a routine home visit for a client
who was discharged home with a colostomy bag?
Observe insertion site
A client with arthritis has been receiving treatment with naproxen and now reports ongoing
stomach pain, increasing weakness and fatigue. Which lab test should the nurse monitor?
Hemoglobin
A client with influenza needs help in transferring to the bedside commode. The nurse observes
the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which
action should the nurse take?
Review the need for the UAP to wear a face mask while in close contact with the client.
A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the client's
therapeutic response to this medication, which assessment should the nurse obtain?
Serum electrolytes.
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to
her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should
the nurse provide to this mother?
Withhold this dose.
The nurse is providing education to a client who experiences recurrent levels of moderate
anxiety to situations and perceived stress. In addition to information about prescribed
medication and administration, which instruction should the nurse include in the teaching?
, Hesi Exit V3 Exam (Actual Exam) Questions and Verified Answers
Practice using muscle relaxation techniques.
The lower limit for normal plasma glucose levels during the first 72 hours after birth is 40
to 45 mg/dL (2.2 to 2.5 mmol/L). Hypoglycemia is most common in the macrocosmic or LGA infant,
but the nurse should monitor blood glucose levels in all infants of mothers with known or
suspected diabetes. Hypoglycemia most frequently occurs within the first 1 to 6 hours after
birth. Signs of hypoglycemia include jitteriness, apnea, tachypnea, hypotonia, decreased
activity, and cyanosis. A Ballard score maturity assessment of 37 corresponds to 37 weeks
gestation, which is a early term. Early term (37 0/7 through 38 6/7 weeks). Compared with
full-term infants, early-term infants are at increased risk for morbidity and mortality.
Normal findings include acrocyanosis, soft fontanelles, Mongolian spots, and Apgar scores of 7
to 10.
The nurse is reviewing the possible complications that can occur for an infant of a diabetic
mother. Choose the most likely options for the information missing from the statement(s) by
selecting from the lists of options provided.
The nurse recognizes that the infant of a diabetic mother is at risk for hyperbilirubinemia,
respiratory distress syndrome, and cardiomyopathy
Glucose level immediately after birth and then at 30 min, 1 hour, 2 hours, 4 hours, 8 and 12
hours and if symptoms suggest hypoglycemla.
• Breastfeed Immediately once stable, then on
demand. If unstable, may feed breast milk via
orogastric tube.
• If two feeding attempts fall to increase the
glucose levels or if symptoms of hypoglycemia
develop, apply dextrose (sugar) gel Inside the
baby's cheek.
, Hesi Exit V3 Exam (Actual Exam) Questions and Verified Answers
• If the above are ineffective, IV glucose should
be administered to maintain glucose levels
above 45 mg/dL (2.5 mmol/L).
Monitor for Respiratory distress, contact respiratory therapy for ABG and oxygen therapy,
blood glucose level, keep in warmer with Bilirubin lights, monitor temperature every 30
minutes, feed immediately
The nurse is reviewing lab work and nurses' notes to determine which actions to
take at this time. Which actions are appropriate for the nurse to take at this time? Select
all that apply.
A Keep infant In warmer with bilirubin lights to maintain temperature of 97.6°
B Inform the mother that the baby is stable enough to take out of the warmer
D Explain to the mother that the baby's respiratory rate needs to be below 60 1
E Observe for signs of respiratory distress and monitor oxygenation by pulse c
Day 1
1800: The client Is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who
was diagnosed with gestational dlabetes. Following a spontaneous vaginal birth, she received
Apgar scores of 7 at 1 min and 8 at 5 min. The client weighs 4036.97 g (8 Ibs. 9 oz) and
appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be
slightly jittery at 30 min of age. Axillary temperature 96° F (35.6° C), pulse 140,
respiratory rate 80. Blood glucose 35 mg/dL (1.9 mmol/L), bilirubin level 7 mg/dL (119.73
umol/L). Fontanelles soft, Mongolian spot noted on lower back, Ballard maturity rating 37
weeks.
Proactive lactation management, strategies, support, and follow-up for late-preterm infants
and some early term infants are important components that affect breastfeeding success.
Prophylactic phototherapy is often used in preterm infants to prevent a significant increase
in serum bilirubin levels. It is also recommended that healthy late-preterm and term infants
(23S weeks of gestation) receive follow-up care and assessment of bilirubin within 3 days of
discharge. Late preterm infants of a diabetic mother need to be monitored more closely.
Parents are taught to evaluate the number of voids and evidence of adequate breastfeeding
, Hesi Exit V3 Exam (Actual Exam) Questions and Verified Answers
after the infant is home. Notify the primary care practitioner if there are indications the
infant is not feeding well, is difficult to arouse for feedings, or is not voiding and
stooling adequately. Seeing the obstetrician at 8 weeks is contraindicated, as most postpartum
visits are between 4 and 6 wecks. ACOG recommends that postpartum care be an ongoing process
in which each woman's individual needs determine the services and support she receives. Early
follow-up is warranted for women who experienced complications such as hypertensive disorders
of pregnancy, those with chronic health conditions, women at high risk for depression, and
breastfeeding mothers who are experiencing feeding problems,
Click to highlight the notes that demonstrate a positive outcome.
Day 2
0630: Vitals have remained stable throughout the night. Oxygen 98% on nasal
canal. Mother to breastfeed in nursery on demand. Able to tolerate breastmilk.
Glucose after feeding was 60 mg/dL (3.3 mmol/L), temp 97.8° F (36.6° C) when
returned to warmer and Bili light. Chest x-ray and echocardiogram results were
normal. Calcium and magnesium within normal llmits, Direct bilirubin 5 mg/dI(5
umol/L), Discharge teaching Initlated, with goal of discharging infant and mother
on day 3.
Studies confirm the importance of maintaining serum glucose levels above 45 mg/dL (25 mmol/1)
in hyper insulinemic infants with hypoglycemia to prevent serious neurologic sequel. Blood
glucose levels continue to improve. Direct bilirubin improved. Other signs of improvement
include a normal temperature for at least 8 hours, improved respiratory status with no signs
of respiratory distress syndrome and feedings are well tolerated.
A client is being discharged with a prescription for warfarin. Which instruction should the
nurse provide this client regarding diet?
Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K
consumed is consistent.
Which assessment should the home health nurse include during a routine home visit for a client
who was discharged home with a colostomy bag?
Observe insertion site
A client with arthritis has been receiving treatment with naproxen and now reports ongoing
stomach pain, increasing weakness and fatigue. Which lab test should the nurse monitor?
Hemoglobin
A client with influenza needs help in transferring to the bedside commode. The nurse observes
the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which
action should the nurse take?
Review the need for the UAP to wear a face mask while in close contact with the client.
A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the client's
therapeutic response to this medication, which assessment should the nurse obtain?
Serum electrolytes.
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to
her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should
the nurse provide to this mother?
Withhold this dose.
The nurse is providing education to a client who experiences recurrent levels of moderate
anxiety to situations and perceived stress. In addition to information about prescribed
medication and administration, which instruction should the nurse include in the teaching?
, Hesi Exit V3 Exam (Actual Exam) Questions and Verified Answers
Practice using muscle relaxation techniques.
The lower limit for normal plasma glucose levels during the first 72 hours after birth is 40
to 45 mg/dL (2.2 to 2.5 mmol/L). Hypoglycemia is most common in the macrocosmic or LGA infant,
but the nurse should monitor blood glucose levels in all infants of mothers with known or
suspected diabetes. Hypoglycemia most frequently occurs within the first 1 to 6 hours after
birth. Signs of hypoglycemia include jitteriness, apnea, tachypnea, hypotonia, decreased
activity, and cyanosis. A Ballard score maturity assessment of 37 corresponds to 37 weeks
gestation, which is a early term. Early term (37 0/7 through 38 6/7 weeks). Compared with
full-term infants, early-term infants are at increased risk for morbidity and mortality.
Normal findings include acrocyanosis, soft fontanelles, Mongolian spots, and Apgar scores of 7
to 10.
The nurse is reviewing the possible complications that can occur for an infant of a diabetic
mother. Choose the most likely options for the information missing from the statement(s) by
selecting from the lists of options provided.
The nurse recognizes that the infant of a diabetic mother is at risk for hyperbilirubinemia,
respiratory distress syndrome, and cardiomyopathy
Glucose level immediately after birth and then at 30 min, 1 hour, 2 hours, 4 hours, 8 and 12
hours and if symptoms suggest hypoglycemla.
• Breastfeed Immediately once stable, then on
demand. If unstable, may feed breast milk via
orogastric tube.
• If two feeding attempts fall to increase the
glucose levels or if symptoms of hypoglycemia
develop, apply dextrose (sugar) gel Inside the
baby's cheek.
, Hesi Exit V3 Exam (Actual Exam) Questions and Verified Answers
• If the above are ineffective, IV glucose should
be administered to maintain glucose levels
above 45 mg/dL (2.5 mmol/L).
Monitor for Respiratory distress, contact respiratory therapy for ABG and oxygen therapy,
blood glucose level, keep in warmer with Bilirubin lights, monitor temperature every 30
minutes, feed immediately
The nurse is reviewing lab work and nurses' notes to determine which actions to
take at this time. Which actions are appropriate for the nurse to take at this time? Select
all that apply.
A Keep infant In warmer with bilirubin lights to maintain temperature of 97.6°
B Inform the mother that the baby is stable enough to take out of the warmer
D Explain to the mother that the baby's respiratory rate needs to be below 60 1
E Observe for signs of respiratory distress and monitor oxygenation by pulse c
Day 1
1800: The client Is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who
was diagnosed with gestational dlabetes. Following a spontaneous vaginal birth, she received
Apgar scores of 7 at 1 min and 8 at 5 min. The client weighs 4036.97 g (8 Ibs. 9 oz) and
appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be
slightly jittery at 30 min of age. Axillary temperature 96° F (35.6° C), pulse 140,
respiratory rate 80. Blood glucose 35 mg/dL (1.9 mmol/L), bilirubin level 7 mg/dL (119.73
umol/L). Fontanelles soft, Mongolian spot noted on lower back, Ballard maturity rating 37
weeks.
Proactive lactation management, strategies, support, and follow-up for late-preterm infants
and some early term infants are important components that affect breastfeeding success.
Prophylactic phototherapy is often used in preterm infants to prevent a significant increase
in serum bilirubin levels. It is also recommended that healthy late-preterm and term infants
(23S weeks of gestation) receive follow-up care and assessment of bilirubin within 3 days of
discharge. Late preterm infants of a diabetic mother need to be monitored more closely.
Parents are taught to evaluate the number of voids and evidence of adequate breastfeeding
, Hesi Exit V3 Exam (Actual Exam) Questions and Verified Answers
after the infant is home. Notify the primary care practitioner if there are indications the
infant is not feeding well, is difficult to arouse for feedings, or is not voiding and
stooling adequately. Seeing the obstetrician at 8 weeks is contraindicated, as most postpartum
visits are between 4 and 6 wecks. ACOG recommends that postpartum care be an ongoing process
in which each woman's individual needs determine the services and support she receives. Early
follow-up is warranted for women who experienced complications such as hypertensive disorders
of pregnancy, those with chronic health conditions, women at high risk for depression, and
breastfeeding mothers who are experiencing feeding problems,
Click to highlight the notes that demonstrate a positive outcome.
Day 2
0630: Vitals have remained stable throughout the night. Oxygen 98% on nasal
canal. Mother to breastfeed in nursery on demand. Able to tolerate breastmilk.
Glucose after feeding was 60 mg/dL (3.3 mmol/L), temp 97.8° F (36.6° C) when
returned to warmer and Bili light. Chest x-ray and echocardiogram results were
normal. Calcium and magnesium within normal llmits, Direct bilirubin 5 mg/dI(5
umol/L), Discharge teaching Initlated, with goal of discharging infant and mother
on day 3.
Studies confirm the importance of maintaining serum glucose levels above 45 mg/dL (25 mmol/1)
in hyper insulinemic infants with hypoglycemia to prevent serious neurologic sequel. Blood
glucose levels continue to improve. Direct bilirubin improved. Other signs of improvement
include a normal temperature for at least 8 hours, improved respiratory status with no signs
of respiratory distress syndrome and feedings are well tolerated.
A client is being discharged with a prescription for warfarin. Which instruction should the
nurse provide this client regarding diet?
Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K
consumed is consistent.
