Exit HESI Exam Test Questions And Answers Verified
100% Correct
A 12 year-old boy who had an appendectomy two days ago is receiving 0.9% normal
saline at 50 ml/hr. His urine specific gravity is 1.035. What action should the nurse
implement?
A) Evaluate postural blood pressure measurements.
B) Obtain a specimen for urinalysis.
C) Encourage popsicles and fluids of choice.
D) Assess bowel sounds in all quadrants. - ANSWER C) Encourage popsicles and
fluids of choice.
Specific gravity of urine is a measurement of hydration status (NR 1.010 to 1.025) which
is indicative of fluid volume deficit); when Sp Gr increases as urine become more
concentrated. The nurse should continue the prescribed IV fluids and increase PO
intake.
The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt
that was placed 2 days after birth. Which findings are an indication of a postoperative
complication? SATA.
A) Poor feeding and vomiting.
B) Leakage of CSF from the incisional site.
C) Hyperactive bowel sounds.
D) Abdominal distention.
E) White blood count of 10,000/mm3. - ANSWER Ans: A, B, D are signs of
postoperative complications.
A couple who is trying to have a baby asks the nurse when they are most likely to
conceive a child. The woman has a regular 36 day cycle and the first day of her LMP
was on January 15. Which information should the nurse provide?
A) Have intercourse every other morning because this is when sperm count is higher.
B) Plan to have intercourse on February 7, as this is when ovulation should occur.
C) Have intercourse every 3 days to ensure that ovulation and intercourse coincide.
D) The woman should ovulate mid-cycle, so plan to have intercourse on February 3. -
ANSWER B) Plan to have intercourse on February 7, as this is when ovulation
should occur.
Ovulation usually occurs 14 days before the first day of the menstrual cycle. The client's
,next menstrual period should begin on February 21 so ovulation should occur on
February 7.
A newborn infant is receiving positive pressure ventilation after delivery. Based on
which assessment finding should the nurse initiate chest compressions?
A) Apgar score of 7
B) Heart rate of 54
C) Central cyanosis
D) Limp muscle tone - ANSWER Ans: B) Heart rate of 54
Chest compressions should be initiated when a newborn's heart rate is less than 60
bpm (B) despite the use of positive pressure ventilation. The Apgar score is obtained at
1 minutes and 5 minutes but a score of 7 is not the criterion used to determine neonatal
response to ventilation.
Which fetal heart pattern requires immediate nursing intervention?
A) An FHR deceleration that mirrors the
contraction.
B) An increase in the FHR to 100 that quickly returns
to baseline.
C) An FHR deceleration that occurs at the same time
of contraction.
D) A decrease in the FHR that occurs after the peak of a contraction.
- ANSWER D) A
decrease in the FHR that occurs after the peak of
contraction.
A decreased FHR after the peak of contraction is an ominous sign and indicates fetal
distress (hypoxia). A and C are describing the same contraction pattern and both are
normal signs of fetal descent. B is a description of FHR acceleration which is normal.
The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a
clear liquid diet following abdominal surgery. Which menu items should the nurse
request for this client? SATA.
A) hot chocolate
B) apple juice
C) chicken broth
D) orange juice
E) black coffee - ANSWER Ans: B, C
Apple juice and chicken broth are included in a clear liquid diet and are consumed by
Mormons. Black coffee (E) is included in a clear liquid diet, but caffeinated beverages
are not consumed by Mormons.
,A nine-day old infant with congenital adrenal hyperplasia (CAH) develops dehydration
and is admitted to the hospital for aldosterone replacement therapy. The HCP
prescribes fludrocortisone acetate (Florinef) 0.05 mg PO daily. Which finding indicates
the newborn is experiencing a therapeutic response?
A) Resting blood pressure of 62/41 mmHg
B) Plasma glucose 45 mg/dl
C) Serum sodium 142 mEq/L
D) Capillary refill is greater than 3 seconds. - ANSWER C) Serum sodium 142 mEq/L
Infants with CAH produce inadequate cortisol and aldosterone that leads to
dehydration and salt-losing crises which require urgent medical intervention.
Aldosterone replacement therapy is prescribed to promote increased reabsorption of
sodium and water int eh distal renal tubules, which should result in a normalization of
serum sodium (134-146).
A client with a cervical spinal cord injury has Crutchfield tongs and skeletal traction
applied as a method. Which intervention is most important for the nurse?
A) Provide daily care of tong insertion site using saline and antibiotic ointment.
B) Modify the client's diet to prevent constipation.
C) Encourage active ROM Q2-4 hours.
D) Instruct the client to report any symptoms of upper extremity paresthesia. -
ANSWER A) Provide daily care of tong insertion site using saline and antibiotic
ointment.
Crutchfield tongs, a skeletal traction device for cervical immobilization requires daily
care of the surgically inserted tongs to minimize the risk of infection of the insertion sites
and cranial bone. Daily cleansing with normal saline solution and antibiotic ointment
applications minimize the bacterial colonization and helps to prevent infections.
Following breakfast, the nurse is preparing to administer 0900 medications to clients on
a medical floor. Which medications should the nurse hold until a later time?
A) Loop diuretic furosemide (Lasix) for a client with a serum potassium level of 4.2
B) The mucosal barrier, sucralfate (Carafate) for a client diagnosed with PUD.
C) The antiplatelet agent aspirin for a client discharged within the hour.
D) The antifungal nystatin suspension for a client who has just brushed his teeth. -
ANSWER B) The mucosal barrier, sucralfate (Carafate) for a client diagnosed with
PUD.
Carafate coasts the mucosal lining prior to eating a meal, so this med should be held
until prior to the next meal. Since the potassium level is (A) within normal limits, there is
, no reason to hold the lasix. The nurse can safely administer (C). In (D), the client should
rinse the mouth prior to administering nystatin swish and swallow but the medication
does not need to be held.
Which interventions should the nurse implement for a client with a superficial (first
degree) burn?
A) Spray an anesthetic agent over the burn every 3-4 hours.
B) Position the burn victim in front of a cool fan to decrease discomfort.
C) Apply ice packs for 30 minutes to lower surface temperature.
D) Place wet cloths on the burned areas for short periods of time. - ANSWER D) Place
wet cloths on the burned areas for short periods of time.
Placing wet cloths on the burned areas for short periods of time (D) provides comfort
and helps to relieve the pain of a first degree burn, which involves only the epidermal
layer of the skin. (A and B) are not likely to provide pain relief. (C) Applying ice for 30
minutes is too long and can result in additional skin damage.
The nurse is teaching a mother of a newborn with a cleft lip on how to bottle feed her
baby using a Haberman feeder that has a valve to control the release of milk and a slit
nipple opening. The nurse discusses placing the nipple's elongated lip to the back of the
oral cavity. What instructions should the nurse provide the mother about feedings?
A) Squeeze the nipple base to introduce milk into the mouth.
B) Position the baby in the left lateral position after feeding.
C) Alternate milk with water during the feeding.
D) Hold the newborn in an upright position. - ANSWER D) Hold the newborn in an
upright position.
The mother should be instructed to hold the infant during feedings in a sitting or upright
position to prevent aspiration. Impaired sucking is compensated by the use of special
feeding appliances and nipples, such as Haberman feeder that prevents aspiration by
adjusting the flow of milk according to the effort of the neonate. Squeezing the nipple
base may introduce a value that is greater than the neonate can coordinate swallowing
(A). The preferred position of an infant after feeding is on the right side (B) to facilitate
stomach emptying. Suckling difficulty impedes the neonate's intake of adquate nutrient
needed for weight gain, and water should be provided after the feeding (D) to cleanse
the oral cavity and not fill up the neonate's stomach.
A male client with terminal cancer is brought to the ED manifesting a Cheyenne Stokes
respiratory pattern. The wife tells the nurse that her husband has an advanced directive
that indicates "Do not resuscitate (DNR) status," but the documents are at home. When
the client becomes apneic and pulseless, what action should the nurse take?
100% Correct
A 12 year-old boy who had an appendectomy two days ago is receiving 0.9% normal
saline at 50 ml/hr. His urine specific gravity is 1.035. What action should the nurse
implement?
A) Evaluate postural blood pressure measurements.
B) Obtain a specimen for urinalysis.
C) Encourage popsicles and fluids of choice.
D) Assess bowel sounds in all quadrants. - ANSWER C) Encourage popsicles and
fluids of choice.
Specific gravity of urine is a measurement of hydration status (NR 1.010 to 1.025) which
is indicative of fluid volume deficit); when Sp Gr increases as urine become more
concentrated. The nurse should continue the prescribed IV fluids and increase PO
intake.
The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt
that was placed 2 days after birth. Which findings are an indication of a postoperative
complication? SATA.
A) Poor feeding and vomiting.
B) Leakage of CSF from the incisional site.
C) Hyperactive bowel sounds.
D) Abdominal distention.
E) White blood count of 10,000/mm3. - ANSWER Ans: A, B, D are signs of
postoperative complications.
A couple who is trying to have a baby asks the nurse when they are most likely to
conceive a child. The woman has a regular 36 day cycle and the first day of her LMP
was on January 15. Which information should the nurse provide?
A) Have intercourse every other morning because this is when sperm count is higher.
B) Plan to have intercourse on February 7, as this is when ovulation should occur.
C) Have intercourse every 3 days to ensure that ovulation and intercourse coincide.
D) The woman should ovulate mid-cycle, so plan to have intercourse on February 3. -
ANSWER B) Plan to have intercourse on February 7, as this is when ovulation
should occur.
Ovulation usually occurs 14 days before the first day of the menstrual cycle. The client's
,next menstrual period should begin on February 21 so ovulation should occur on
February 7.
A newborn infant is receiving positive pressure ventilation after delivery. Based on
which assessment finding should the nurse initiate chest compressions?
A) Apgar score of 7
B) Heart rate of 54
C) Central cyanosis
D) Limp muscle tone - ANSWER Ans: B) Heart rate of 54
Chest compressions should be initiated when a newborn's heart rate is less than 60
bpm (B) despite the use of positive pressure ventilation. The Apgar score is obtained at
1 minutes and 5 minutes but a score of 7 is not the criterion used to determine neonatal
response to ventilation.
Which fetal heart pattern requires immediate nursing intervention?
A) An FHR deceleration that mirrors the
contraction.
B) An increase in the FHR to 100 that quickly returns
to baseline.
C) An FHR deceleration that occurs at the same time
of contraction.
D) A decrease in the FHR that occurs after the peak of a contraction.
- ANSWER D) A
decrease in the FHR that occurs after the peak of
contraction.
A decreased FHR after the peak of contraction is an ominous sign and indicates fetal
distress (hypoxia). A and C are describing the same contraction pattern and both are
normal signs of fetal descent. B is a description of FHR acceleration which is normal.
The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a
clear liquid diet following abdominal surgery. Which menu items should the nurse
request for this client? SATA.
A) hot chocolate
B) apple juice
C) chicken broth
D) orange juice
E) black coffee - ANSWER Ans: B, C
Apple juice and chicken broth are included in a clear liquid diet and are consumed by
Mormons. Black coffee (E) is included in a clear liquid diet, but caffeinated beverages
are not consumed by Mormons.
,A nine-day old infant with congenital adrenal hyperplasia (CAH) develops dehydration
and is admitted to the hospital for aldosterone replacement therapy. The HCP
prescribes fludrocortisone acetate (Florinef) 0.05 mg PO daily. Which finding indicates
the newborn is experiencing a therapeutic response?
A) Resting blood pressure of 62/41 mmHg
B) Plasma glucose 45 mg/dl
C) Serum sodium 142 mEq/L
D) Capillary refill is greater than 3 seconds. - ANSWER C) Serum sodium 142 mEq/L
Infants with CAH produce inadequate cortisol and aldosterone that leads to
dehydration and salt-losing crises which require urgent medical intervention.
Aldosterone replacement therapy is prescribed to promote increased reabsorption of
sodium and water int eh distal renal tubules, which should result in a normalization of
serum sodium (134-146).
A client with a cervical spinal cord injury has Crutchfield tongs and skeletal traction
applied as a method. Which intervention is most important for the nurse?
A) Provide daily care of tong insertion site using saline and antibiotic ointment.
B) Modify the client's diet to prevent constipation.
C) Encourage active ROM Q2-4 hours.
D) Instruct the client to report any symptoms of upper extremity paresthesia. -
ANSWER A) Provide daily care of tong insertion site using saline and antibiotic
ointment.
Crutchfield tongs, a skeletal traction device for cervical immobilization requires daily
care of the surgically inserted tongs to minimize the risk of infection of the insertion sites
and cranial bone. Daily cleansing with normal saline solution and antibiotic ointment
applications minimize the bacterial colonization and helps to prevent infections.
Following breakfast, the nurse is preparing to administer 0900 medications to clients on
a medical floor. Which medications should the nurse hold until a later time?
A) Loop diuretic furosemide (Lasix) for a client with a serum potassium level of 4.2
B) The mucosal barrier, sucralfate (Carafate) for a client diagnosed with PUD.
C) The antiplatelet agent aspirin for a client discharged within the hour.
D) The antifungal nystatin suspension for a client who has just brushed his teeth. -
ANSWER B) The mucosal barrier, sucralfate (Carafate) for a client diagnosed with
PUD.
Carafate coasts the mucosal lining prior to eating a meal, so this med should be held
until prior to the next meal. Since the potassium level is (A) within normal limits, there is
, no reason to hold the lasix. The nurse can safely administer (C). In (D), the client should
rinse the mouth prior to administering nystatin swish and swallow but the medication
does not need to be held.
Which interventions should the nurse implement for a client with a superficial (first
degree) burn?
A) Spray an anesthetic agent over the burn every 3-4 hours.
B) Position the burn victim in front of a cool fan to decrease discomfort.
C) Apply ice packs for 30 minutes to lower surface temperature.
D) Place wet cloths on the burned areas for short periods of time. - ANSWER D) Place
wet cloths on the burned areas for short periods of time.
Placing wet cloths on the burned areas for short periods of time (D) provides comfort
and helps to relieve the pain of a first degree burn, which involves only the epidermal
layer of the skin. (A and B) are not likely to provide pain relief. (C) Applying ice for 30
minutes is too long and can result in additional skin damage.
The nurse is teaching a mother of a newborn with a cleft lip on how to bottle feed her
baby using a Haberman feeder that has a valve to control the release of milk and a slit
nipple opening. The nurse discusses placing the nipple's elongated lip to the back of the
oral cavity. What instructions should the nurse provide the mother about feedings?
A) Squeeze the nipple base to introduce milk into the mouth.
B) Position the baby in the left lateral position after feeding.
C) Alternate milk with water during the feeding.
D) Hold the newborn in an upright position. - ANSWER D) Hold the newborn in an
upright position.
The mother should be instructed to hold the infant during feedings in a sitting or upright
position to prevent aspiration. Impaired sucking is compensated by the use of special
feeding appliances and nipples, such as Haberman feeder that prevents aspiration by
adjusting the flow of milk according to the effort of the neonate. Squeezing the nipple
base may introduce a value that is greater than the neonate can coordinate swallowing
(A). The preferred position of an infant after feeding is on the right side (B) to facilitate
stomach emptying. Suckling difficulty impedes the neonate's intake of adquate nutrient
needed for weight gain, and water should be provided after the feeding (D) to cleanse
the oral cavity and not fill up the neonate's stomach.
A male client with terminal cancer is brought to the ED manifesting a Cheyenne Stokes
respiratory pattern. The wife tells the nurse that her husband has an advanced directive
that indicates "Do not resuscitate (DNR) status," but the documents are at home. When
the client becomes apneic and pulseless, what action should the nurse take?
