HESI EXIT 5- 160 QUESTIONS
WITH MULTIPLE CHOICES AND
VERIFIED ANSWERS
Suicide precautions are initiated for a child admitted to the mental
health unit following an intentional narcotic overdose. After a visitor
leaves, the nurse finds a package of cigarettes in the client's room.
Which intervention is most important for the nurse to implement?
- ANS- Remove cigarettes for the client's room
A family member of a frail elderly adult asks the nurse about eligibility
requirements for hospice care. What information should the nurse
provide? (Select all that apply.)
A.) A client must be willing to accept palliative care, not curative care.
B.) The healthcare provider must project that the client has 6 months or
less to live.
C.) The client must be diagnosed with clinical depression
D.) The client must be of sound mind
- ANS- A,B
A client with atrial fibrillation receives a new prescription for dabigatran.
What instruction should the nurse include in this client's teaching plan?
- ANS- Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
An infant who is admitted for surgical repair of a ventricular septal
defect (VSD) is irritable and diaphoretic with jugular vein distention.
Which prescription should the nurse administer first?
- ANS- Digoxin
The nursing staff on a medical unit includes a registered nurse (RN),
practical nurse (PN), and an unlicensed assistive personnel (UAP).
Which task should the charge nurse assign to the RN?
- ANS- Supervise a newly hired graduate nurse during an admission
assessment.
While teaching a young male adult to use an inhaler for his newly
diagnosed asthma, the client stares into the distance and appears to be
concentrating on something
,other than the lesson the nurse is presenting. What action should the
nurse take?
- ANS- Ask the client what he is thinking about at his time.
After several hours of non-productive coughing, a client presents to the
emergency room complaining of chest tightness and shortness of breath.
History includes end stage chronic obstructive pulmonary disease
(COPD) and diabetes mellitus. While completing the pulmonary
assessment, the nurse hears wheezing and poor air movement
bilaterally. Which actions should the nurse implement? (Select all that
apply.)
A.) Administer PRN nebulizer treatment.
B.) Obtain 12 lead electrocardiogram.
C.) Monitor continuous oxygen saturation.
D.) Lay the client in the prone position
- ANS- A,B,C
The nurse caring for a 3-month-old boy one day after a pylorotomy
notices that the infant is restless, is exhibiting facial grimaces, and is
drawing his knees to his chest. What action should the nurse take?
- ANS- Administer a prescribed analgesia for pain.
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a
chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal,
MIX), an antimetabolite. Which information should the nurse provide
the parents about caring for their child?
- ANS- Use sunblock or protective clothing when outdoors.
Two days after admission a male client remembers that he is allergic to
eggs, and informs the nurse of the allergy. Which actions should the
nurse implement? SATA
A.) Tell the client that its a mild reaction
B.) Notify the food services department of the allergy.
C.) Enter the allergy information in the client's record.
D.) Add egg allergy to the client's allergy arm band.
- ANS- B,C,D
The rapid response team's detects return of spontaneous circulation
(ROSC) after 2 min of continuous chest compressions. The client has a
weak, fast pulse and no respiratory effort, so the healthcare provider
,performs a successful oral, intubation.
, What action should the nurse implement?
- ANS- Perform bilateral chest auscultation.
After administering an antipyretic medication. Which intervention
should the nurse implement?
- ANS- Encouraging liberal fluid intake
A client with hyperthyroidism is being treated with radioactive iodine (I-
131). Which explanation should be included in preparing this client for
this treatment?
- ANS- Describe radioactive iodine as a tasteless, colorless medication
administered by the healthcare provider
After a colon resection for colon cancer, a male client is moaning while
being transferred to the Postanesthesia Care Unit (PACU). Which
intervention should the nurse implement first?
- ANS- Determine client's pulse, blood pressure, and respirations
The nurse is caring for a group of clients with the help of a licensed
practical nurse (LPN) and an experienced unlicensed assistive personnel
(UAP). Which procedures can the nurse delegate to the UAP? (Select all
that apply)
A.) Take postoperative vital signs for a client who has an epidual
following knee arthroplasty
B.) Collect a sputum specimen for a client with a fever of unknown origin
C.) Ambulate a client who had a femoral-popliteal bypass graft yesterday
- ANS- A,B,C
A male client with cirrhosis has ascites and reports feeling short of
breath. The client is in semi Fowler position with his arms at his side.
What action should the nurse implement?
- ANS- Raise the head of the bed to a Fowler's position and support his
arms with a pillow
A client with a history of chronic pain requests a nonopioid analgesic.
The client is alert but has difficulty describing the exact nature and
location of the pain to the nurse. Which action should the nurse
implement next?
- ANS- Administer the analgesic as requested
The nurse uses the parkland formula (4ml x kg x total body surface area =
24 hours fluid replacement) to calculate the 24-hours IV fluid replacement
for a client with 40% burns who weighs 76kg. How many ml should the
client receive? (Enter numeric
WITH MULTIPLE CHOICES AND
VERIFIED ANSWERS
Suicide precautions are initiated for a child admitted to the mental
health unit following an intentional narcotic overdose. After a visitor
leaves, the nurse finds a package of cigarettes in the client's room.
Which intervention is most important for the nurse to implement?
- ANS- Remove cigarettes for the client's room
A family member of a frail elderly adult asks the nurse about eligibility
requirements for hospice care. What information should the nurse
provide? (Select all that apply.)
A.) A client must be willing to accept palliative care, not curative care.
B.) The healthcare provider must project that the client has 6 months or
less to live.
C.) The client must be diagnosed with clinical depression
D.) The client must be of sound mind
- ANS- A,B
A client with atrial fibrillation receives a new prescription for dabigatran.
What instruction should the nurse include in this client's teaching plan?
- ANS- Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
An infant who is admitted for surgical repair of a ventricular septal
defect (VSD) is irritable and diaphoretic with jugular vein distention.
Which prescription should the nurse administer first?
- ANS- Digoxin
The nursing staff on a medical unit includes a registered nurse (RN),
practical nurse (PN), and an unlicensed assistive personnel (UAP).
Which task should the charge nurse assign to the RN?
- ANS- Supervise a newly hired graduate nurse during an admission
assessment.
While teaching a young male adult to use an inhaler for his newly
diagnosed asthma, the client stares into the distance and appears to be
concentrating on something
,other than the lesson the nurse is presenting. What action should the
nurse take?
- ANS- Ask the client what he is thinking about at his time.
After several hours of non-productive coughing, a client presents to the
emergency room complaining of chest tightness and shortness of breath.
History includes end stage chronic obstructive pulmonary disease
(COPD) and diabetes mellitus. While completing the pulmonary
assessment, the nurse hears wheezing and poor air movement
bilaterally. Which actions should the nurse implement? (Select all that
apply.)
A.) Administer PRN nebulizer treatment.
B.) Obtain 12 lead electrocardiogram.
C.) Monitor continuous oxygen saturation.
D.) Lay the client in the prone position
- ANS- A,B,C
The nurse caring for a 3-month-old boy one day after a pylorotomy
notices that the infant is restless, is exhibiting facial grimaces, and is
drawing his knees to his chest. What action should the nurse take?
- ANS- Administer a prescribed analgesia for pain.
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a
chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal,
MIX), an antimetabolite. Which information should the nurse provide
the parents about caring for their child?
- ANS- Use sunblock or protective clothing when outdoors.
Two days after admission a male client remembers that he is allergic to
eggs, and informs the nurse of the allergy. Which actions should the
nurse implement? SATA
A.) Tell the client that its a mild reaction
B.) Notify the food services department of the allergy.
C.) Enter the allergy information in the client's record.
D.) Add egg allergy to the client's allergy arm band.
- ANS- B,C,D
The rapid response team's detects return of spontaneous circulation
(ROSC) after 2 min of continuous chest compressions. The client has a
weak, fast pulse and no respiratory effort, so the healthcare provider
,performs a successful oral, intubation.
, What action should the nurse implement?
- ANS- Perform bilateral chest auscultation.
After administering an antipyretic medication. Which intervention
should the nurse implement?
- ANS- Encouraging liberal fluid intake
A client with hyperthyroidism is being treated with radioactive iodine (I-
131). Which explanation should be included in preparing this client for
this treatment?
- ANS- Describe radioactive iodine as a tasteless, colorless medication
administered by the healthcare provider
After a colon resection for colon cancer, a male client is moaning while
being transferred to the Postanesthesia Care Unit (PACU). Which
intervention should the nurse implement first?
- ANS- Determine client's pulse, blood pressure, and respirations
The nurse is caring for a group of clients with the help of a licensed
practical nurse (LPN) and an experienced unlicensed assistive personnel
(UAP). Which procedures can the nurse delegate to the UAP? (Select all
that apply)
A.) Take postoperative vital signs for a client who has an epidual
following knee arthroplasty
B.) Collect a sputum specimen for a client with a fever of unknown origin
C.) Ambulate a client who had a femoral-popliteal bypass graft yesterday
- ANS- A,B,C
A male client with cirrhosis has ascites and reports feeling short of
breath. The client is in semi Fowler position with his arms at his side.
What action should the nurse implement?
- ANS- Raise the head of the bed to a Fowler's position and support his
arms with a pillow
A client with a history of chronic pain requests a nonopioid analgesic.
The client is alert but has difficulty describing the exact nature and
location of the pain to the nurse. Which action should the nurse
implement next?
- ANS- Administer the analgesic as requested
The nurse uses the parkland formula (4ml x kg x total body surface area =
24 hours fluid replacement) to calculate the 24-hours IV fluid replacement
for a client with 40% burns who weighs 76kg. How many ml should the
client receive? (Enter numeric
