HESI RN EXIT EXAM 2024 HESI Nursing
Nightingale College - Question and answers
correctly solved 2024 HIGHLY GRADED A+
What preoperative nursing intervention should be included in the plan of care for an
infant with pyloric stenosis? - CORRECT ANSWERS--Observe for projectile vomiting
A six month old returns from surgery with elbow restraints in place. What nursing
intervention should be included when caring for any restrained child? - CORRECT
ANSWERS--remove restraints one at a time and provide range of motion exercise
A two year old with Down Syndrome is brought to the clinic for his regular physical
exam. The nurse knows which problem is frequently associated with Down Syndrome? -
CORRECT ANSWERS--Congenital Heart Disease
When assessing a child with asthma the nurse should expect intercostal retractions
during - CORRECT ANSWERS--inspiration
When planning the care for a child who has had a cleft lip repair, the nurse knows that
crying should be minimized because it - CORRECT ANSWERS--stresses the suture
line
A client with a productive cough has obtained a sputum specimen for culture as
instructed. What action is the best initial nursing action? - CORRECT ANSWERS--
Administer the first dose of prescribed antibiotic therapy
A client is brought to the Emergency Department by ambulance in cardiac arrest with
CPR in progress. The client is intubated and receiving 100% O2 per ambu bag. The
nurse determines the client is cyanotic, cold, and diaphoretic. Which assessment is
most important to obtain? - CORRECT ANSWERS--deep tendon reflexes
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a
client develops pontine myselinolysis. Which intervention should the nurse implement
first? - CORRECT ANSWERS--Reorientate client to his room
A male client with heart failure (HF) calls the clinic and reports he cannot put his shoes
on because they are too tight. Which additional information should the nurse obtain? -
CORRECT ANSWERS--Has his weight changed in the last several days
,An older adult with a long hx of COPD is admitted with progressive shortness of breath
and a persistent cough. She is anxious and is complaining of a dry mouth. Which
intervention should the nurse implement? - CORRECT ANSWERS--Apply a high flow
venturi mask
A client with a hx of asthma and bronchitis arrives at the clinic with SOB, productive
cough with thickened tenacious mucous and the inability to walk up a flight of stairs
without experiencing breathlessness. Which action is important for the nurse to instruct
the client about self care? - CORRECT ANSWERS--Increase the daily intake of oral
fluids to to liquefy secretions
A cardiac catherization of a client with heart disease indicates the following blockages
95% LAD 99% proximal circumflex and 95% proximal RCA. The client later asks the
nurse "what does all that mean for me" - CORRECT ANSWERS--3 main arteries have
major blockages with only 1 to 5% of blood flow getting through to the heart muscle
The nurse is caring for a client with a lower left pulmonary abscess which position
should the nurse instruct the client to maintain - CORRECT ANSWERS--left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable
to eat or drink without nausea and vomiting. Which finding should the nurse report to the
healthcare provider - CORRECT ANSWERS--yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a
neuro assessment every 4 hours. which assessment finding warrants immediate
intervention by the nurse? - CORRECT ANSWERS--Increasing Anxiety
The nurse is providing preoperative education for a Jewish client scheduled to receive a
xenograft to promote burn healing. Which info should the nurse provide this client? -
CORRECT ANSWERS--The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requests assistance to
reposition. The wound dehiscences and eviscerates. The nurse moistens an available
sterile dressing and places it over the wound which intervention should the nurse
implement next? - CORRECT ANSWERS--prepare the client to return to the operating
room
A client with carcinoma of the lung is complaining of weakness and has a serum sodium
level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan
of care? - CORRECT ANSWERS--Fluid volume excess
A female client enters the clinic and insists on being seen. She is weak, nervous, and
reports a racing heart beat and recent weight loss of 15 pounds. After ruling out
substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her
for further testing. Which action should the nurse implement? - CORRECT ANSWERS--
space the clients care to provide periods of rest
, The nurse is teaching the client with glomerulonephritis about self care which dietary
recommendations should the nurse encourage the client to follow? - CORRECT
ANSWERS--restrict intake by limiting meats and other high protein foods
An overweight, young adult male who was recently diagnosed with type 2 diabetes
mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak
and jittery. Which actions should the nurse implement? - CORRECT ANSWERS---
assess his skin temp and moisture
- document anxiety on the surgical checklist
-administer a PRN dose of regular insulin
A client with Cushings Syndrome is recovering from an elective laparoscopic procedure.
Which assessment finding warrants immediate intervention by the nurse? - CORRECT
ANSWERS--irregular apical pulse
An adult client with primary Raynauds phenomenon develops pallor and then cyanosis
of her finger. After warming her hands the fingers turn red and the client reports a
burning sensation. What action should the nurse take? - CORRECT ANSWERS--secure
a pulse oximeter to monitor the clients oxygen saturation
A male client with muscular dystrophy fell in his home and is admitted with a right hip
fracture. His right foot is cool with palpable pedal pulses. Lungs are coarse with
diminished breath sounds. Vital signs are temp 101, heart rate 128 bpm, respirations 28
bpm and BP 122/82 . Which intervention is most important for the nurse to implement
first? - CORRECT ANSWERS--Assess lower extremity circulation
The nurse is completing preoperative assessment of a client who is scheduled for a
laparoscopic cholecystectomy under general anesthesia. Which finding warrants
notification of the healthcare provider? - CORRECT ANSWERS--The clients blood
pressure is 184/88
A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants immediate action from the nurse? -
CORRECT ANSWERS--hematocrit of 30%
Following surgical repair of the bladder a female client is being discharged from the
hospital with an indwelling catheter. Which instruction is most important for the nurse to
provide to the client? - CORRECT ANSWERS--Keep the drainage bag lower than the
level of the bladder
Which client has the highest risk for developing skin cancer - CORRECT ANSWERS--a
65 year old fair skinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assessment is most important
for the nurse to obtain? - CORRECT ANSWERS--level of consciousness
Nightingale College - Question and answers
correctly solved 2024 HIGHLY GRADED A+
What preoperative nursing intervention should be included in the plan of care for an
infant with pyloric stenosis? - CORRECT ANSWERS--Observe for projectile vomiting
A six month old returns from surgery with elbow restraints in place. What nursing
intervention should be included when caring for any restrained child? - CORRECT
ANSWERS--remove restraints one at a time and provide range of motion exercise
A two year old with Down Syndrome is brought to the clinic for his regular physical
exam. The nurse knows which problem is frequently associated with Down Syndrome? -
CORRECT ANSWERS--Congenital Heart Disease
When assessing a child with asthma the nurse should expect intercostal retractions
during - CORRECT ANSWERS--inspiration
When planning the care for a child who has had a cleft lip repair, the nurse knows that
crying should be minimized because it - CORRECT ANSWERS--stresses the suture
line
A client with a productive cough has obtained a sputum specimen for culture as
instructed. What action is the best initial nursing action? - CORRECT ANSWERS--
Administer the first dose of prescribed antibiotic therapy
A client is brought to the Emergency Department by ambulance in cardiac arrest with
CPR in progress. The client is intubated and receiving 100% O2 per ambu bag. The
nurse determines the client is cyanotic, cold, and diaphoretic. Which assessment is
most important to obtain? - CORRECT ANSWERS--deep tendon reflexes
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a
client develops pontine myselinolysis. Which intervention should the nurse implement
first? - CORRECT ANSWERS--Reorientate client to his room
A male client with heart failure (HF) calls the clinic and reports he cannot put his shoes
on because they are too tight. Which additional information should the nurse obtain? -
CORRECT ANSWERS--Has his weight changed in the last several days
,An older adult with a long hx of COPD is admitted with progressive shortness of breath
and a persistent cough. She is anxious and is complaining of a dry mouth. Which
intervention should the nurse implement? - CORRECT ANSWERS--Apply a high flow
venturi mask
A client with a hx of asthma and bronchitis arrives at the clinic with SOB, productive
cough with thickened tenacious mucous and the inability to walk up a flight of stairs
without experiencing breathlessness. Which action is important for the nurse to instruct
the client about self care? - CORRECT ANSWERS--Increase the daily intake of oral
fluids to to liquefy secretions
A cardiac catherization of a client with heart disease indicates the following blockages
95% LAD 99% proximal circumflex and 95% proximal RCA. The client later asks the
nurse "what does all that mean for me" - CORRECT ANSWERS--3 main arteries have
major blockages with only 1 to 5% of blood flow getting through to the heart muscle
The nurse is caring for a client with a lower left pulmonary abscess which position
should the nurse instruct the client to maintain - CORRECT ANSWERS--left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable
to eat or drink without nausea and vomiting. Which finding should the nurse report to the
healthcare provider - CORRECT ANSWERS--yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a
neuro assessment every 4 hours. which assessment finding warrants immediate
intervention by the nurse? - CORRECT ANSWERS--Increasing Anxiety
The nurse is providing preoperative education for a Jewish client scheduled to receive a
xenograft to promote burn healing. Which info should the nurse provide this client? -
CORRECT ANSWERS--The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requests assistance to
reposition. The wound dehiscences and eviscerates. The nurse moistens an available
sterile dressing and places it over the wound which intervention should the nurse
implement next? - CORRECT ANSWERS--prepare the client to return to the operating
room
A client with carcinoma of the lung is complaining of weakness and has a serum sodium
level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan
of care? - CORRECT ANSWERS--Fluid volume excess
A female client enters the clinic and insists on being seen. She is weak, nervous, and
reports a racing heart beat and recent weight loss of 15 pounds. After ruling out
substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her
for further testing. Which action should the nurse implement? - CORRECT ANSWERS--
space the clients care to provide periods of rest
, The nurse is teaching the client with glomerulonephritis about self care which dietary
recommendations should the nurse encourage the client to follow? - CORRECT
ANSWERS--restrict intake by limiting meats and other high protein foods
An overweight, young adult male who was recently diagnosed with type 2 diabetes
mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak
and jittery. Which actions should the nurse implement? - CORRECT ANSWERS---
assess his skin temp and moisture
- document anxiety on the surgical checklist
-administer a PRN dose of regular insulin
A client with Cushings Syndrome is recovering from an elective laparoscopic procedure.
Which assessment finding warrants immediate intervention by the nurse? - CORRECT
ANSWERS--irregular apical pulse
An adult client with primary Raynauds phenomenon develops pallor and then cyanosis
of her finger. After warming her hands the fingers turn red and the client reports a
burning sensation. What action should the nurse take? - CORRECT ANSWERS--secure
a pulse oximeter to monitor the clients oxygen saturation
A male client with muscular dystrophy fell in his home and is admitted with a right hip
fracture. His right foot is cool with palpable pedal pulses. Lungs are coarse with
diminished breath sounds. Vital signs are temp 101, heart rate 128 bpm, respirations 28
bpm and BP 122/82 . Which intervention is most important for the nurse to implement
first? - CORRECT ANSWERS--Assess lower extremity circulation
The nurse is completing preoperative assessment of a client who is scheduled for a
laparoscopic cholecystectomy under general anesthesia. Which finding warrants
notification of the healthcare provider? - CORRECT ANSWERS--The clients blood
pressure is 184/88
A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants immediate action from the nurse? -
CORRECT ANSWERS--hematocrit of 30%
Following surgical repair of the bladder a female client is being discharged from the
hospital with an indwelling catheter. Which instruction is most important for the nurse to
provide to the client? - CORRECT ANSWERS--Keep the drainage bag lower than the
level of the bladder
Which client has the highest risk for developing skin cancer - CORRECT ANSWERS--a
65 year old fair skinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assessment is most important
for the nurse to obtain? - CORRECT ANSWERS--level of consciousness
