Exit HESI Exam Study Guide Questions And Answers
Verified 100% Correct
An older client with atrial fibrillation receives a new prescription for Dabigatran to reduce
the risk of blood clot formation. What information should the nurse include in this client's
medication teaching plan? SATA.
A) Medication injections are self-administered daily.
B) Plan to monitor and record the pulse rate daily.
C) Contact the HCP if bruising occurs.
D) Report bleeding in the urine or stool right away.
E) Inform the dentist of medication usage before the procedure. - ANSWER Ans: C, D,
E
Dabigatran is an oral anticoagulant used to decrease clot formation in atrial fibrillation,
thus reducing the risk for stroke.
The home health nurse is visiting an older client who was discharged form the hospital 3
days ago following hip pinning surgery. Which meal choices should the nurse suggest
for this client's diet? SATA.
A) Low fat milk
B) Oat bran
C) White rice
D) Grilled salmon
E) Baked chicken - ANSWER Ans: A, B, D, E
Dairy products such as low fat milk provide calcium, Vitamin D, and protein. Salmon and
tuna fish are high in omega 3. Oat bran provides Vitamin D which promotes absorption
of dietary calcium. Decreased mobility following hip surgery combined with slower
peristalsis leads to constipation, so including oat bran foods provides increased dietary
fiber. Baked chicken provides protein which is important for healing.
A male client returns to the mental health clinic for assistance with his anxiety reaction
that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving
over the bay bridge. What action in the treatment plan should the nurse implement?
A. Tell the client to drive over the bridge until fear is manageable
B. Teach the client to listen to music or audiobooks while driving
,C. Encourage the client to have spouse drive in stressful places
D. Recommend that the client avoid driving over the bridge - ANSWER B. Teach client
to listen to music or audio books while driving
Desensitization is a component in the treatment plan for client's with panic attacks which
is best approached with anxiety-reducing strategies such as listening to audio books
during situations that precipitate symptoms.
A young adult female presents at the ED with acute lower abdominal pain. Which
assessment finding is most important for the nurse to report to the HCP?
A) Pain scale rating is a 9 out of 10.
B) LMP was 7 weeks ago.
C) Reports white, curdy vaginal discharge.
D) History of IBS. - ANSWER B) LMP was 7 weeks ago.
Acute lower abdominal pain in a young adult female can be indicative of ectopic
pregnancy which can be life threatening.
An older female client is admitted to the ICU with severe abdominal pain, abdominal
distension, and absent bowel sounds. She has a hx of smoking 2 packs of cigarettes
daily for 50 years and is currently restless and confused. Vital signs are temperature 96
F, 122 bpm, RR 36/min, MAP 64 mmHg, and CVP 7 mm Hg. Serum lab findings
include: Hgb 6.5, platelets 60,0000, and WBC 3,000. Based on these findings, this client
is at greatest risk for which condition?
A) Multiple organ dysfunction syndrome (MODS)
B) Disseminated intravascular coagulation (DIC)
C) Chronic obstructive pulmonary disease (COPD)
D) Acquired immunodeficiency syndrome (AIDS) - ANSWER A) Multiple organ
dysfunction syndrome (MODS)
MODS is a progressive dysfunction of two or more major organs that requires medical
intervention to maintain homeostasis. This client has several organ systems that require
intervention, such as BP, Hgb, WBC, and RR.
An adult male with severe depression was admitted to psychiatric unit yesterday
evening. Although the client ran a marathon one year ago, his wife states that he no
longer runs, but sits and watches television most of the day. Which intervention is most
important for the nurse to include in this client's plan of care for today?
A) Assist client in identifying his goals for the day.
B) Encourage client to participate for one hour on a team sport.
,C) Schedule client for a group that focuses on self-esteem.
D) Help client to develop a list of daily affirmations. - ANSWER A) Assist client in
identifying his goals for the day.
Client with severe depression have low energy and benefit from structured activities
because concentration is decreased. Having the client participate in his care by
identifying his goals for the day (A) is the most important intervention for his first day on
the unit. B, C, and D can be implemented over time as his depression decreases.
The legs of a client who is receiving hospice care have become mottled in appearance.
When the nurse observes the unlicensed assistive personnel (UAP) place a heating pad
on the mottled areas, what action should the nurse take?
A. Remove the heating pads and pace a soft blanket over the client's legs and feet
B. Advise the UAP to observe the client's skin while the heating pads are in place
C. Evaluate the client's feet on a pillow and monitor the client's pedal pulses frequently
D. Instruct the UAP to reposition the heating pads to the sides of the legs and feet -
ANSWER A. Remove the heating pads and pace a soft blanket over the client's legs
and feet
Mottling occurs as circulation diminishes and death approaches. Heating pads provide
warmth but may damage the client's skin due to diminished sensation, so the heating
pad should be replaced with soft blankets to provide comfort and warmth. The heating
pad should be removed.
The nurse is initiating IV fluid replacement for a child who has dry, sticky, mucous
membranes, flushed skin, and a fever of 103.4 F. Laboratory findings indicate that the
child has a serum sodium concentration of 156. What physiologic mechanism
contributes to this finding?
A) The IV fluid replacement contains a hypertonic solution of sodium chloride.
B) Urinary and gastrointestinal fluid loss reduce blood viscosity and stimulate thirst.
C) Insensible loss of body fluids contributes to the hemoconcentration of serum solutes.
D) Hypothalamic resettling of core body temperature causes vasodilation to reduce
body heat. - ANSWER C) Insensible loss of body fluids contributes to the
hemoconcentration of serum solutes.
Fever causes insensible fluid loss which contributes to fluid volume deficit and results in
hemoconcentration of sodium.
While changing a client's chest tube dressing, the nurse notes a crackling sensation
when gentle pressure is applied to the skin at the insertion site. What action would be
best for the nurse to take?
, A) Apply a pressure dressing around the chest tube insertion site.
B) Assess the client for allergies to topical cleaning agents.
C) Measure the area of swelling and crackling.
D) Administer an oral antihistamine per PRN protocol. - ANSWER C) Measure the area
of swelling and crackling.
A crackling sensation or crepitus indicates subcutaneous emphysema, or air leaking
into the skin. This area should be measured and the finding documented.
A client with acute renal failure is admitted for uncontrolled type 1 DM and
hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale.
Which intervention is most important for the nurse to include in this client's plan of care?
A) Monitor the client's cardiac activity via telemetry.
B) Maintain venous access with an infusion of normal saline.
C) Assess glucose via fingerstick Q4-6 hours.
D) Evaluate hourly urine output for return of normal renal funciton. - ANSWER A)
Monitor the client's cardiac activity via telemetry.
As insulin lowers the blood glucose of a client with DKA, potassium returns to the cell
but may not impact hyperkalemia related to acute renal failure. The priority is to monitor
the client for cardiac dysthymia related to abnormal serum potassium level.
A male client presents to the clinic with large draining ulcers on his lower legs that are
characteristic of Kapok's sarcoma lesions. He is accompanied by two family members.
What actions should the nurse take?
A. Ask the family members to wear gloves when touching the client
B. Send family to the waiting area while the client's history is taken
C. Obtain a blood sample to determine of the client is HIV positive
D. Complete a head to toe assessment to identify other signs of HIV - ANSWER B.
Send family to the waiting area while the client's history is taken
To protect the client's privacy, the family members should be asked to wait outside
while the client's history is taken. Gloves should be worn when touching the client's
body fluids (A). if he is HIV positive and these lesions are actually Kaposi's sarcoma
lesions. HIV testing (C) cannot legally be done without the client's consent. (D) can be
implemented after the family has left the client.
The nurse is preparing to send a client to the cardiac cath lab for elective cardioversion.
Which interventions should the nurse implement before the client leaves the medical
unit?
Verified 100% Correct
An older client with atrial fibrillation receives a new prescription for Dabigatran to reduce
the risk of blood clot formation. What information should the nurse include in this client's
medication teaching plan? SATA.
A) Medication injections are self-administered daily.
B) Plan to monitor and record the pulse rate daily.
C) Contact the HCP if bruising occurs.
D) Report bleeding in the urine or stool right away.
E) Inform the dentist of medication usage before the procedure. - ANSWER Ans: C, D,
E
Dabigatran is an oral anticoagulant used to decrease clot formation in atrial fibrillation,
thus reducing the risk for stroke.
The home health nurse is visiting an older client who was discharged form the hospital 3
days ago following hip pinning surgery. Which meal choices should the nurse suggest
for this client's diet? SATA.
A) Low fat milk
B) Oat bran
C) White rice
D) Grilled salmon
E) Baked chicken - ANSWER Ans: A, B, D, E
Dairy products such as low fat milk provide calcium, Vitamin D, and protein. Salmon and
tuna fish are high in omega 3. Oat bran provides Vitamin D which promotes absorption
of dietary calcium. Decreased mobility following hip surgery combined with slower
peristalsis leads to constipation, so including oat bran foods provides increased dietary
fiber. Baked chicken provides protein which is important for healing.
A male client returns to the mental health clinic for assistance with his anxiety reaction
that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving
over the bay bridge. What action in the treatment plan should the nurse implement?
A. Tell the client to drive over the bridge until fear is manageable
B. Teach the client to listen to music or audiobooks while driving
,C. Encourage the client to have spouse drive in stressful places
D. Recommend that the client avoid driving over the bridge - ANSWER B. Teach client
to listen to music or audio books while driving
Desensitization is a component in the treatment plan for client's with panic attacks which
is best approached with anxiety-reducing strategies such as listening to audio books
during situations that precipitate symptoms.
A young adult female presents at the ED with acute lower abdominal pain. Which
assessment finding is most important for the nurse to report to the HCP?
A) Pain scale rating is a 9 out of 10.
B) LMP was 7 weeks ago.
C) Reports white, curdy vaginal discharge.
D) History of IBS. - ANSWER B) LMP was 7 weeks ago.
Acute lower abdominal pain in a young adult female can be indicative of ectopic
pregnancy which can be life threatening.
An older female client is admitted to the ICU with severe abdominal pain, abdominal
distension, and absent bowel sounds. She has a hx of smoking 2 packs of cigarettes
daily for 50 years and is currently restless and confused. Vital signs are temperature 96
F, 122 bpm, RR 36/min, MAP 64 mmHg, and CVP 7 mm Hg. Serum lab findings
include: Hgb 6.5, platelets 60,0000, and WBC 3,000. Based on these findings, this client
is at greatest risk for which condition?
A) Multiple organ dysfunction syndrome (MODS)
B) Disseminated intravascular coagulation (DIC)
C) Chronic obstructive pulmonary disease (COPD)
D) Acquired immunodeficiency syndrome (AIDS) - ANSWER A) Multiple organ
dysfunction syndrome (MODS)
MODS is a progressive dysfunction of two or more major organs that requires medical
intervention to maintain homeostasis. This client has several organ systems that require
intervention, such as BP, Hgb, WBC, and RR.
An adult male with severe depression was admitted to psychiatric unit yesterday
evening. Although the client ran a marathon one year ago, his wife states that he no
longer runs, but sits and watches television most of the day. Which intervention is most
important for the nurse to include in this client's plan of care for today?
A) Assist client in identifying his goals for the day.
B) Encourage client to participate for one hour on a team sport.
,C) Schedule client for a group that focuses on self-esteem.
D) Help client to develop a list of daily affirmations. - ANSWER A) Assist client in
identifying his goals for the day.
Client with severe depression have low energy and benefit from structured activities
because concentration is decreased. Having the client participate in his care by
identifying his goals for the day (A) is the most important intervention for his first day on
the unit. B, C, and D can be implemented over time as his depression decreases.
The legs of a client who is receiving hospice care have become mottled in appearance.
When the nurse observes the unlicensed assistive personnel (UAP) place a heating pad
on the mottled areas, what action should the nurse take?
A. Remove the heating pads and pace a soft blanket over the client's legs and feet
B. Advise the UAP to observe the client's skin while the heating pads are in place
C. Evaluate the client's feet on a pillow and monitor the client's pedal pulses frequently
D. Instruct the UAP to reposition the heating pads to the sides of the legs and feet -
ANSWER A. Remove the heating pads and pace a soft blanket over the client's legs
and feet
Mottling occurs as circulation diminishes and death approaches. Heating pads provide
warmth but may damage the client's skin due to diminished sensation, so the heating
pad should be replaced with soft blankets to provide comfort and warmth. The heating
pad should be removed.
The nurse is initiating IV fluid replacement for a child who has dry, sticky, mucous
membranes, flushed skin, and a fever of 103.4 F. Laboratory findings indicate that the
child has a serum sodium concentration of 156. What physiologic mechanism
contributes to this finding?
A) The IV fluid replacement contains a hypertonic solution of sodium chloride.
B) Urinary and gastrointestinal fluid loss reduce blood viscosity and stimulate thirst.
C) Insensible loss of body fluids contributes to the hemoconcentration of serum solutes.
D) Hypothalamic resettling of core body temperature causes vasodilation to reduce
body heat. - ANSWER C) Insensible loss of body fluids contributes to the
hemoconcentration of serum solutes.
Fever causes insensible fluid loss which contributes to fluid volume deficit and results in
hemoconcentration of sodium.
While changing a client's chest tube dressing, the nurse notes a crackling sensation
when gentle pressure is applied to the skin at the insertion site. What action would be
best for the nurse to take?
, A) Apply a pressure dressing around the chest tube insertion site.
B) Assess the client for allergies to topical cleaning agents.
C) Measure the area of swelling and crackling.
D) Administer an oral antihistamine per PRN protocol. - ANSWER C) Measure the area
of swelling and crackling.
A crackling sensation or crepitus indicates subcutaneous emphysema, or air leaking
into the skin. This area should be measured and the finding documented.
A client with acute renal failure is admitted for uncontrolled type 1 DM and
hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale.
Which intervention is most important for the nurse to include in this client's plan of care?
A) Monitor the client's cardiac activity via telemetry.
B) Maintain venous access with an infusion of normal saline.
C) Assess glucose via fingerstick Q4-6 hours.
D) Evaluate hourly urine output for return of normal renal funciton. - ANSWER A)
Monitor the client's cardiac activity via telemetry.
As insulin lowers the blood glucose of a client with DKA, potassium returns to the cell
but may not impact hyperkalemia related to acute renal failure. The priority is to monitor
the client for cardiac dysthymia related to abnormal serum potassium level.
A male client presents to the clinic with large draining ulcers on his lower legs that are
characteristic of Kapok's sarcoma lesions. He is accompanied by two family members.
What actions should the nurse take?
A. Ask the family members to wear gloves when touching the client
B. Send family to the waiting area while the client's history is taken
C. Obtain a blood sample to determine of the client is HIV positive
D. Complete a head to toe assessment to identify other signs of HIV - ANSWER B.
Send family to the waiting area while the client's history is taken
To protect the client's privacy, the family members should be asked to wait outside
while the client's history is taken. Gloves should be worn when touching the client's
body fluids (A). if he is HIV positive and these lesions are actually Kaposi's sarcoma
lesions. HIV testing (C) cannot legally be done without the client's consent. (D) can be
implemented after the family has left the client.
The nurse is preparing to send a client to the cardiac cath lab for elective cardioversion.
Which interventions should the nurse implement before the client leaves the medical
unit?
