HESI LEADERSHIP EXIT EXAM VERSION 1 WITH ACTUAL
ANSWERS GRADED A+!!
1. The nurse is caring for an older adult who was admitted with a Urinary tract infection and is now
exhibiting signs of Severe Inflammatory Response Syndrome (SIRS). Which collaborative care goals
should the nurse include in the plan of care? (Select all that apply)
BODY TEMP with in normal limits.
REDUCE WBC count.
NEGATIVE URINE CULTURE
The nurse is caring for clients on an orthopedic unit. Which client has the greatest risk for developing
osteomyelitis?
OLDER ADULT W/OSTEOPOROSIS WHO IS BEDFAST FOLLOWING COMPRESSION FRACTURE OF THE
VERTABRAE
. A male college student is brought to an emergency clinic by his friends because they report that he has
been vomiting for the past 3 days as the result of food poisoning. Laboratory findings indicate that the
client's potassium level is 2.5 mEq/L (2.5 mmol/L), so he is admitted to a local hospital, Which
intervention is most important for the nurse to include in this client's plan of care?
Initiate cardiac monitoring for the clients.
The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative
home care the day. Which intervention should the nurse ask the PN to ensure the family is providing the
client?
MUCOUS MEMBRANE MOIST
The nurse is caring for a group of five clients with the assistance of an experienced and capable
unlicensed assistive personnel (UAP). Which nursing actions can the nurse delegate to the UP? (Select all
that apply.)
POST OP VITAL SIGNS
HYGIENE CARE FOLLOWING TRAUMATIC FOOT AMPUTATION
When triaging emergency room clients, which client should the nurse assess first?
FEMALE WITH SEVERE RIGHT LOWER ABDOMINAL PAIN FEBRILE AND VOMITING *Confirm
While eating breakfast, a client admitted with syncope and a 2-month history of vertigo complains of
dizziness. Using the standard communication tool SBAR (Situation, Background, Assessment,
Recommendation), which statement is best for the nurse to provide the healthcare provider about the
client's background?
The client's significant history includes atrial fibrillation and hypoglycemia.
Page 1 of 7
, Several nurses are elected by their peers to serve on a negotiating committee to recommend new
healthcare benefits
BE AVAILABLE TO ALL SHIFTS TO DISCUSS CHANGES IN HEALTH BENEFITS
Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed
assistive one of the visitors is lying on the client's bed. Which action should the nurse implement?
EXPLAIN THE CLIENT HAS THE RIGHT TO HAVE VISITOR LIE ON THE BED
. The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the
medication was also given on the fourth day.
REVIEW MEDICATION TRANSCRIPTION WITH THE NURSE.
. The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC)
when a code blue is called for another collapsed in the hallway while ambulating with the unlicensed
assistive personnel (UAP). Which action should the nurse take
Respond to the code. OR Finish the procedure Not sure
Which client requires the most immediate intervention by the nurse?
CLIENT WITH ACUTE KIDNEY INJURY who is somnolent and does respond to verbal commands.
. The nurse receives a telephone prescription from the healthcare provider for a client's persistent cough
and wheezing, The prescription includes a chest xray, an antibiotic, and a nebulizer treatment now and
PRN. Alter reading the prescription back to the healthcare provider to ensure accuracy, which
intervention should the nurse implement first?
NEBULIZER BREATHING TREATMENT
An experienced, female practical nurse (PN) is hired to work on the surgical unit of a tertiary hospital.
The first day she is working on the unit, the PN tells the charge nurse that she has excellent wound care
skills. It is a busy day and a postoperative client needs to have a sterile dressing change. Which action is
best for the charge nurse to take?
Watch the PN perform sterile wound care to validate her skill level
A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung
cancer. He tells the nurse that he does not want to be "hooked up to any machines". His vital signs are
heart rate 120 beats/minute, blood pressure 98/50 mm, respirations 30 breaths/minute, and oxygen
saturation rate is 88%. Which action should the nurse take?
Discontinue the intravenous infusion
A child is admitted to the pediatric unit after being diagnosed with pertussis. The nurse observes an
unlicensed assistive personnel (UP) donning on a pair of gloves before entering the room to give the
child a popsicle. Which action should the nurse take?
REVIEW THE NEED TO WEAR A FACE MASK WHILE IN CLOSE CONTACT.
Page 2 of 7
ANSWERS GRADED A+!!
1. The nurse is caring for an older adult who was admitted with a Urinary tract infection and is now
exhibiting signs of Severe Inflammatory Response Syndrome (SIRS). Which collaborative care goals
should the nurse include in the plan of care? (Select all that apply)
BODY TEMP with in normal limits.
REDUCE WBC count.
NEGATIVE URINE CULTURE
The nurse is caring for clients on an orthopedic unit. Which client has the greatest risk for developing
osteomyelitis?
OLDER ADULT W/OSTEOPOROSIS WHO IS BEDFAST FOLLOWING COMPRESSION FRACTURE OF THE
VERTABRAE
. A male college student is brought to an emergency clinic by his friends because they report that he has
been vomiting for the past 3 days as the result of food poisoning. Laboratory findings indicate that the
client's potassium level is 2.5 mEq/L (2.5 mmol/L), so he is admitted to a local hospital, Which
intervention is most important for the nurse to include in this client's plan of care?
Initiate cardiac monitoring for the clients.
The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative
home care the day. Which intervention should the nurse ask the PN to ensure the family is providing the
client?
MUCOUS MEMBRANE MOIST
The nurse is caring for a group of five clients with the assistance of an experienced and capable
unlicensed assistive personnel (UAP). Which nursing actions can the nurse delegate to the UP? (Select all
that apply.)
POST OP VITAL SIGNS
HYGIENE CARE FOLLOWING TRAUMATIC FOOT AMPUTATION
When triaging emergency room clients, which client should the nurse assess first?
FEMALE WITH SEVERE RIGHT LOWER ABDOMINAL PAIN FEBRILE AND VOMITING *Confirm
While eating breakfast, a client admitted with syncope and a 2-month history of vertigo complains of
dizziness. Using the standard communication tool SBAR (Situation, Background, Assessment,
Recommendation), which statement is best for the nurse to provide the healthcare provider about the
client's background?
The client's significant history includes atrial fibrillation and hypoglycemia.
Page 1 of 7
, Several nurses are elected by their peers to serve on a negotiating committee to recommend new
healthcare benefits
BE AVAILABLE TO ALL SHIFTS TO DISCUSS CHANGES IN HEALTH BENEFITS
Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed
assistive one of the visitors is lying on the client's bed. Which action should the nurse implement?
EXPLAIN THE CLIENT HAS THE RIGHT TO HAVE VISITOR LIE ON THE BED
. The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the
medication was also given on the fourth day.
REVIEW MEDICATION TRANSCRIPTION WITH THE NURSE.
. The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC)
when a code blue is called for another collapsed in the hallway while ambulating with the unlicensed
assistive personnel (UAP). Which action should the nurse take
Respond to the code. OR Finish the procedure Not sure
Which client requires the most immediate intervention by the nurse?
CLIENT WITH ACUTE KIDNEY INJURY who is somnolent and does respond to verbal commands.
. The nurse receives a telephone prescription from the healthcare provider for a client's persistent cough
and wheezing, The prescription includes a chest xray, an antibiotic, and a nebulizer treatment now and
PRN. Alter reading the prescription back to the healthcare provider to ensure accuracy, which
intervention should the nurse implement first?
NEBULIZER BREATHING TREATMENT
An experienced, female practical nurse (PN) is hired to work on the surgical unit of a tertiary hospital.
The first day she is working on the unit, the PN tells the charge nurse that she has excellent wound care
skills. It is a busy day and a postoperative client needs to have a sterile dressing change. Which action is
best for the charge nurse to take?
Watch the PN perform sterile wound care to validate her skill level
A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung
cancer. He tells the nurse that he does not want to be "hooked up to any machines". His vital signs are
heart rate 120 beats/minute, blood pressure 98/50 mm, respirations 30 breaths/minute, and oxygen
saturation rate is 88%. Which action should the nurse take?
Discontinue the intravenous infusion
A child is admitted to the pediatric unit after being diagnosed with pertussis. The nurse observes an
unlicensed assistive personnel (UP) donning on a pair of gloves before entering the room to give the
child a popsicle. Which action should the nurse take?
REVIEW THE NEED TO WEAR A FACE MASK WHILE IN CLOSE CONTACT.
Page 2 of 7
