NEW HESI EXIT PN EXAM A PRACTICE QUESTION
WITH
RATIONALES AND Q&A TESTED AND APPROVED!!!
A male client is admitted for observation after being hit on the head with a baseball bat. Six
hours after admission, the client attempts to crawl out of bed and asks the nurse why there are
so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on
room air. Which intervention should the nurse perform first?
A. Administer oxygen per nasal cannula at 2 L/min.
B. Plan to check his vital signs again in 30 minutes.
C. Notify the health care provider of the change in mental status.
D. Ask the client why he thinks there are bugs in the bed. -- ANSWER--C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental status
(C). It is important to act early and quickly when symptoms of increased ICP occur. Because
his oxygen saturation is normal, the administration of oxygen (A) is not the top priority. Vital
signs should be monitored frequently (B), but the client's confusion should be reported
immediately. (D) is not a useful intervention.
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client?
A. High Fowler's position without a pillow behind the head
B. Semi-Fowler's position with a single pillow behind the head
C. Right side-lying position with the head of the bed elevated 45 degrees
D. Sitting upright and forward with both arms supported on an over the bed table --
ANSWER--D
Page 1 of 53
,Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to
increase the longitudinal and anterior-posterior size of the thoracic cage. Sitting upright and
leaning forward with the arms supported on an over the bed table (D) allows the thoracic cage
to expand in all four directions and reduces dyspnea. A high Fowler's position does not allow
maximum expansion of the posterior lobes of the lungs (A). A semi-Fowler's position
restricts expansion of the anterior-posterior diameter of the thoracic cage (B). Positioning a
client on the right side with the head of the bed elevated (C) does not facilitate lung
expansion.
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide
(HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the
client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's
potassium level?
A.The client is noncompliant with his medications.
B.The client recently consumed large quantities of pears or nuts.
C.The client's renal function has affected his potassium level.
D.The client needs to be started on a potassium supplement. -- ANSWER--C
The client has a normalized potassium level despite diuretic use (C). The kidney
automatically secretes 90% of potassium consumed, but in chronic renal insufficiency (CRI),
less potassium is excreted than normal. Therefore, the two potassium-wasting drugs, a
thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The normal
potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is no reason
to believe that the client is noncompliant with his treatment (A). Pears and nuts do not affect
the serum potassium level (B). There is no need for a potassium supplement (D) because the
client's potassium level is within the normal range.
A registered nurse (RN) delivers telehealth services to clients via electronic communication.
Which nursing action creates the greatest risk for professional liability and has the potential
for a malpractice lawsuit?
Page 2 of 53
,A.Participating in telephone consultations with clients
B.Identifying oneself by name and title to clients in telehealth communications
C.Sending medical records to health care providers via the Internet
D.Answering a client-initiated health question via electronic mail -- ANSWER--C
Sending medical records over the Internet, even with the latest security protection, creates the
greatest risk for liability because of the high potential of breaching client confidentiality and
the amount of information being transferred (C). Client confidentiality is protected by federal
wiretapping laws making telephone consultation (A) a private and protected form of
communication. By stating one's name and credentials in telehealth communication (B), one
is taking responsibility for the encounter. E-mail initiated by the client (D) poses less risk
than sending records via the Internet.
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish
and swallow. Which information is most important for the nurse to provide the client? A.Oral
hygiene should be performed before the medication.
B.Antifungal medications are available in tablet, suppository, and liquid forms.
C.Candida albicans is the organism that causes the white lesions in the mouth.
D.The dietary intake of dairy and spicy foods should be limited. -- ANSWER--A
HIV infection causes depression of cell-mediated immunity that allows an overgrowth of
Candida albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that
resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral
liquids should be consumed and oral hygiene performed before swishing the liquid
Mycostatin (A). (B and C) provide the client with additional information about the
pathogenesis and treatment of opportunistic infections, but (A) allows the client to participate
in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort
associated with stomatitis, but restriction of dairy products is not indicated (D).
Page 3 of 53
, A nurse who has recently completed orientation is beginning work in the labor and
delivery unit for the first time. When making assignments, which client should the charge
nurse assign to this new nurse?
A.A primigravida who is 8 cm dilated after 14 hours of labor
B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation
C.A client being induced for fetal demise at 20 weeks' gestation
D.A multiparous client who is dilated 5 cm and 50% effaced -- ANSWER--D
The new nurse should be assigned the least complicated client to gain experience and
confidence, as well as protect client safety. Of the clients available for assignment, (D) is
progressing well and is the least complicated. (A, B and C) have actual or potential
complications and should be assigned to a more experienced nurse.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this disaster
are not yet known. Which instruction should the charge nurse give to the other staff members
at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received. -- ANSWER--D
When faced with an impending disaster, hospital personnel may be alerted but should
continue with current client care assignments until further instructions are received (D).
Evacuation is typically a response of last resort that begins with clients who are most able to
ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are
anticipated. (C) is poor utilization of personnel.
Page 4 of 53
WITH
RATIONALES AND Q&A TESTED AND APPROVED!!!
A male client is admitted for observation after being hit on the head with a baseball bat. Six
hours after admission, the client attempts to crawl out of bed and asks the nurse why there are
so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on
room air. Which intervention should the nurse perform first?
A. Administer oxygen per nasal cannula at 2 L/min.
B. Plan to check his vital signs again in 30 minutes.
C. Notify the health care provider of the change in mental status.
D. Ask the client why he thinks there are bugs in the bed. -- ANSWER--C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental status
(C). It is important to act early and quickly when symptoms of increased ICP occur. Because
his oxygen saturation is normal, the administration of oxygen (A) is not the top priority. Vital
signs should be monitored frequently (B), but the client's confusion should be reported
immediately. (D) is not a useful intervention.
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client?
A. High Fowler's position without a pillow behind the head
B. Semi-Fowler's position with a single pillow behind the head
C. Right side-lying position with the head of the bed elevated 45 degrees
D. Sitting upright and forward with both arms supported on an over the bed table --
ANSWER--D
Page 1 of 53
,Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to
increase the longitudinal and anterior-posterior size of the thoracic cage. Sitting upright and
leaning forward with the arms supported on an over the bed table (D) allows the thoracic cage
to expand in all four directions and reduces dyspnea. A high Fowler's position does not allow
maximum expansion of the posterior lobes of the lungs (A). A semi-Fowler's position
restricts expansion of the anterior-posterior diameter of the thoracic cage (B). Positioning a
client on the right side with the head of the bed elevated (C) does not facilitate lung
expansion.
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide
(HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the
client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's
potassium level?
A.The client is noncompliant with his medications.
B.The client recently consumed large quantities of pears or nuts.
C.The client's renal function has affected his potassium level.
D.The client needs to be started on a potassium supplement. -- ANSWER--C
The client has a normalized potassium level despite diuretic use (C). The kidney
automatically secretes 90% of potassium consumed, but in chronic renal insufficiency (CRI),
less potassium is excreted than normal. Therefore, the two potassium-wasting drugs, a
thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The normal
potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is no reason
to believe that the client is noncompliant with his treatment (A). Pears and nuts do not affect
the serum potassium level (B). There is no need for a potassium supplement (D) because the
client's potassium level is within the normal range.
A registered nurse (RN) delivers telehealth services to clients via electronic communication.
Which nursing action creates the greatest risk for professional liability and has the potential
for a malpractice lawsuit?
Page 2 of 53
,A.Participating in telephone consultations with clients
B.Identifying oneself by name and title to clients in telehealth communications
C.Sending medical records to health care providers via the Internet
D.Answering a client-initiated health question via electronic mail -- ANSWER--C
Sending medical records over the Internet, even with the latest security protection, creates the
greatest risk for liability because of the high potential of breaching client confidentiality and
the amount of information being transferred (C). Client confidentiality is protected by federal
wiretapping laws making telephone consultation (A) a private and protected form of
communication. By stating one's name and credentials in telehealth communication (B), one
is taking responsibility for the encounter. E-mail initiated by the client (D) poses less risk
than sending records via the Internet.
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish
and swallow. Which information is most important for the nurse to provide the client? A.Oral
hygiene should be performed before the medication.
B.Antifungal medications are available in tablet, suppository, and liquid forms.
C.Candida albicans is the organism that causes the white lesions in the mouth.
D.The dietary intake of dairy and spicy foods should be limited. -- ANSWER--A
HIV infection causes depression of cell-mediated immunity that allows an overgrowth of
Candida albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that
resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral
liquids should be consumed and oral hygiene performed before swishing the liquid
Mycostatin (A). (B and C) provide the client with additional information about the
pathogenesis and treatment of opportunistic infections, but (A) allows the client to participate
in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort
associated with stomatitis, but restriction of dairy products is not indicated (D).
Page 3 of 53
, A nurse who has recently completed orientation is beginning work in the labor and
delivery unit for the first time. When making assignments, which client should the charge
nurse assign to this new nurse?
A.A primigravida who is 8 cm dilated after 14 hours of labor
B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation
C.A client being induced for fetal demise at 20 weeks' gestation
D.A multiparous client who is dilated 5 cm and 50% effaced -- ANSWER--D
The new nurse should be assigned the least complicated client to gain experience and
confidence, as well as protect client safety. Of the clients available for assignment, (D) is
progressing well and is the least complicated. (A, B and C) have actual or potential
complications and should be assigned to a more experienced nurse.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this disaster
are not yet known. Which instruction should the charge nurse give to the other staff members
at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received. -- ANSWER--D
When faced with an impending disaster, hospital personnel may be alerted but should
continue with current client care assignments until further instructions are received (D).
Evacuation is typically a response of last resort that begins with clients who are most able to
ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are
anticipated. (C) is poor utilization of personnel.
Page 4 of 53
