HESI Exit Exam 2 Graded A+ 2025

1. Male client admitted the morning of scheduled surgery told nurse he drank water last night. Amount of water and what time was taken. 2. Why would nurse apply pressure to lacrimal duct after optic meds? Reduce systemic effects. 3. Comatose patient mouth care. Side lying position. 4. Morning care client have seizure. Protect Pt head. 5. Charge nurse assign PN. Insulin injections. 6. 2 doses missing. Complete report. 7. Pt on suicide ask about discharge. Increases suicide precautions. 8. Photo of chest and locating apical HR. Just below left nipple. 9. At the end of 12hr shift the nurse observes the urine in a client’s drainage. Most recent white blood count. 10. Male client diagnosed with schizophrenia is withdrawn, isolates himself, with one or two- word responses. Measure appropriate vital signs. 11. 8-year-old on 90-90 traction for a fractured femur. Weights are touching the foot of the bed. 12. Nurse reviewing diet instructions with female client who has hyper and increased her intakes of protein and calories. Continue dietary changes she has made. 13. Discontinue IV therapy infusing at 150ml per hour at 1200 the pn notes that there are 750ml of solution remaining. 1700. 14. The PN is caring for a client who had a total laryngectomy, left radical neck dissection... Client is receiving nasogastric tube feedings via an internal pump. Today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding? Gastric residual volumes. 15. A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take? Ensure that all the areolar tissue of the nipple is in the infant’s mouth. 16. Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? Deltoid. 17. A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort? Wear a supportive bra at all times. 18. A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client “This type. Hospital" what intervention should the PN implement. Act as the clients advocate when discussing the issue with the HCP. 19. A client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the PN implement in response to the client’s refusal. Emphasize the importance of active foot flexion. 20. A client recovering from a stroke is learning how to use a cane. How should it be placed. On the stronger side of the body. 21. A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client. Measure all emesis accurately. 22. On admission to the medical unit a client who is homeless and has a history of HIV with persistent cough? Erythema and indurations of 5mm at site. 23. When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given in the computer. What action should the PN take? Contact the medication nurse to clarify the findings. 24. The PN is implementing the plan of care for a client who admits having...indicates the highest risk for the client acting on these suicidal thoughts. Begins to show signs of improvement. 25. The PN observes that a male clients urinary catheter drainage tubing is...the attached to the bed frame. What action should the PN implement? Observe the appearance of the urine in the drainage tubing. 26. A client’s chief complaint is being able to swallow only small bites of solid food...PN should assess for what additional information? History of alcohol and tobacco use. 27. When the PN plans daily care for a group pf client, which client should the PN see first due to the risk of complication? An older client with a stroke who is febrile and confused. 28. When entering the room of an older female resident of a long-term care facility, the PN finds one of the male residents in bed with her. What action should the PN take? Close the door and report the finding to the charge nurse. 29. Prior to giving digoxin, the PN assesses that a 2-month-old infants heart rate is 120 beats/min. Based on this finding what action should the PN take. Give the medication and document the heart rate. 30. A client reports feeling numbness and tingling in extremities. What action should the PN implement. Review the client’s serum electrolyte levels. 31. A 0800 a client’s apical pulse rate is 98 beats/minute Four hours later the apical pulse rate is 54 beats/minute. What action should the PN take next. Determine the level of consciousness. 32. A 5-year-old child is admitted with full thickness burns over 30% of the total body surface areas (TBSA). After fluid replacement therapy is initiated, which finding should the PN use to evaluate the effectiveness of the therapy. Urine output. 33. Direct Coombs' test newborn Positive. Administer Rh immune globulin. 34. When repositioning patient, the nurse observes wound with a foul odor the nurse should. Check the white blood cell count. 35. Prior to administering a prescribed tube feeding to a client with a gastrostomy tube why would the practical nurse aspirate for gastric residual volume. The evaluate the amount of gastric emptying. 36. Admin oxygen to infant with Tetralogy of Fallot nurse intervention Hold in knee to chest position 37. Client report numbness and tingling what lab values should the nurse check Electrolytes 38. Client cough and spit large amount of frothy saliva for sputum collection Reteach client cough techniques. 39. Homeless male with history of alcohol abuse, CVA accident, presents with edema and pain in left leg. Inspect leg for infection or trauma. 40. Mother wants to take 9-month-old infant with RSV to birthday party Don’t expose other children virus is contagious. 41. PICTURE urine bag. Note latest WBC or check finger glucose. 42. Instrument obtained for Weber test. Tuning fork. 43. Mother breast feeding for first time reports nipple pain when baby suck. Ensure nipple is in infant’s mouth. 44. PICTURE bp cuff. Demonstrate how to palpate a brachial pulse. 45. Elderly man wakes and wanders at 3:30am. Address client to determine needs. 46. 5yr old with otitis externa. Gently pull lobe up and back. 47. Pt has NG tube hooked to sucking after admin meds. Clamp tube for 30min after meds. 48. 24hr infant regurgitate nurse should. Suction oral and nasal passage. 49. Female client has hemorrhoids that are flamed and hurt constantly. Position client in left lateral position inspect the perineal area. 50. Daughter claims mother was mistreated overnight. Ask for description of what happened. 51. PICTURE prepares to suction oropharynx. Initiate intermediate suction. 52. Pt has truncal obesity, buffalo hump, and moon face. Corticosteroids. 53. Single mother in room crying with child can’t cope. Recommend that she stays calm and positive. 54. Client receives 20 units of insulin, 4hr later becomes shaky and diaphoretic. Give milk and crackers. 55. Male college student roommate hears voices saying kill. Are you planning to obey these voices? 56. Total laryngectomy, what parameters should nurse take to evaluate feeding. Gastric residual volume. 57. 10yr old diabetic, important question for nurse to ask. Did you perform a fingerstick? 58. UAP can work with (SATA). -daily skin care -morning care -toileting 59. Place in order: -ruptured appendix -severe headache -wandering -discharge instruction 60. Client receiving antibiotic for infection, report. Hives with protasis. 61. Client receiving Fentanyl for pain. Recommend foods high in fiber. 62. Which preop Pt require immediate care? Following the suture removal. The wound dehiscence. 63. Glasgow coma scale nurse should evaluate LOC. 64. Adult client with 40% burns should report. Urine output of 20 ml. 65. Wheelchair bound elderly person activity. Group ring toss competition. 66. Focused assessment for young adult nutritional status. 24hr diet history. 67. Applying hand sanitizer. Place one hand on top of another and intertwine them. 68. Following a total hip replacement. Keep hips aligned with knees abducted. 69. 8-year-old in 90-90 traction for femur fracture, require further action. Weights touching foot of bed. 70. Compound fracture left ankle with below the knee cast discharge teaching. Never scratch under the cast. 71. Client with cirrhosis experiencing peripheral neuropathy. Protect client from injury. 72. T1N0M0 stands for. -tumor size -node involvement -metastasis 73. Instruct postpartum Pt to report. Sudden or persistent temp of 100.5. 74. Severely depressed client exhibits. Disorder of sleep. 75. Small fire breaks out in kitchen, nurse should. Method of transport and evaluate. 76. PICTURE place X on apical heart rate. 5th intercostal space. 77. Assessment finding for client with pneumonia SATA -lung crackles -dyspnea -painful cough 78. 3-year-old have minor surgery. Point to nose and say nose. 79. 20yr old with history of tobacco complains of difficulty swallowing and dyspnea, what other finding. Hoarse voice. 80. LPN and UAP find unresponsive pt, UAP should. Obtain emergency help. 81. Pt has fistula, complains of palpable buzzing sensation, nurse should. Loosen fistula dressing or document. 82. Client receives new prescription at 1000, discontinue IV antibiotic, what to give at 1300. Ampicillin 500mg. 83. PICTURE radial pulse. Teach UAP correct site for radial pulse. 84. Pregnant women with anemia teaching (SATA). -eat more beans -add leafy green vegetables -oatmeal 85. PICTURE applying sequential compression device. Under closest to ankle. 86. Child admitted for tonic colonic seizure, nurse should implement what at next episode (SATA). -hold extremities close to the body -pad side rails -observe progression of seizure 87. Older male client takes psychotropic meds, has uncontrollable movements. Screen for tardive dyskinesia. 88. New mother with engorged breast. Wear supportive bra at all times. 89. Native American female has medication wheel dr. Doesn’t approve, nurse should Act as clients advocate. 90. Pt with acute kidney injury has abnormal labs, high bp, etc. Nurse should. Monitor for dependent edema. 91. A female client takes herbs instead of the pre hypertensive meds Inform Pt of the risk. 92. Difficulty breathing is related to what part of the brain being injured Medulla. 93. Following cardiac catheterization, nurse should report. Faint pedal pulses. 94. Nurse preparing to transfer Pt to chair, who requires assistance. Pt impaired cognition and agitated. 95. Turning a dependent bedridden Pt, to ensure safety. Put bed rails up on opposite side. 96. 18yr old female with mild mental disability, best response. I’ll be back in 30min to help you ambulate. 97. One day postop of appendectomy, complains of tightness and SOB. Have client sit down in hallway. 98. Laryngectomy, left radial neck dissection. Perform routine stoma/suture care. 99. Tingling sensation of nose, fingertips, ear lobe 24hr after thyroidectomy. Give calcium gluconate. 100. Nurse should see who first due to risk of complication. Older adult Pt who is febrile and confused. 101. Oil retention enema regarding temp. Clients body temp. 102. Cocaine withdrawal. Powerful craving for more. 103. Suicidal Pt at greatest risk. Shows signs of improvement. 104. 25-year-old in active labor, two-year-old at home. -Grava 2 -para 1 105. Can’t feel fundus and large amount of blood. Empty bladder. 106. Distraction techniques. Think of past family event. 107. Bone marrow aspiration site. Posterior iliac crest. 108. Female unproductive cough bp 108/58, r 22, p 94. Notify charge nurse. 109. Nurse notices erythema on right hip. Change position every 2hrs. 110. Remove saline lock (SATA): -exam gloves -3ml syringe -gauze -tape 111. Ondansetron before chemo. Monitor for nausea and vomiting. 112. Emptying a Hemovac drain PUT IN ORDER: -apply gloves -remove drainage -compress -lock plug 113. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for eight hours, how many ml of full-strength feeding will the nurse need? (Enter numeric value only.) 200 ml. 114. An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? Apply an external condom catheter. 115. 3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement? Reschedule administration of the antibiotic until after he completes his prayers. 116. UAP using a hand sanitizer that is alcohol for 2 minutes. tell that hand sanitizer use is less 2min. 117. 5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The child weighs 44 pounds. How many mg of the medication should the nurse administer? 800 mg. 118. 6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather than trickles from the vagina. The uterine fundus is firm, and the client's vital signs are pulse 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take next? Compare current vital signs with previous vital signs. 119. A 6-year-old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye. Which action should the school nurse take? Have the parent take the child for emergency help. 120. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of "Altered thought processes, secondary to" what condition? Postpartum psychosis. 121. The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual cramps" for a 25-year-old female client. Which self-care activity should the nurse emphasize in the client's teaching plan? Regular aerobic exercise. 122. Psych/Alcohol/Tylenol overdose antidote.